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// 


No.  187. — New  Series. 


July,  1887. 


610.5 

ftGl5  THE 

AMERICAN  JOURNAL 


MEDICAL  SCIENCES. 

(the  international  journal  of  the  medical  sciences.) 
Published.  Simultaneously  in  Philadelphia  and  London. 

edited  by 

I.  MINIS  HAYS,  A.M.,  M.D., 

PHILADELPHIA, 
AND 

MALCOLM  MORRIS,  M.R.C.S., 


PHILADELPHIA: 

LEA  BEOTHERS  &  CO. 

LONDON: 

CASSELL  &  COMPANY,  Limited. 
1887. 


Subscription,  Fiye  Dollars  a  Year,  Postpaid. 


Copyright  1887,  by  Lea  Brothers  &  Co.  AH  rights  reserved. 
Entered  at  the  Post-Office  at  Philadelphia  as  Second-class  matter. 


ANNOUNCEMENTS. 


SCHREIBER  ON  MASSAGE. — Just  Ready. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Exer- 
cise. By  Joseph  Schreiber.  Translated  from  the  German  by  Walter  Mendelson,  M.D., 
of  New  York.  In  one  handsome  octavo  volume  of  274  pages,  with  117  fine  engravings.  Cloth, 
$2.75. 


CHAPMAN'S  HUMAN  PHYSIOLOGY.— In  Press. 

A  Treatise  on  Human  Physiology.    By  Henry  C.  Chapman,  M.D., 

Professor  of  the  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical 
College  of  Philadelphia.  In  one  very  handsome  octavo  volume  of  about  900  pages,  profusely 
illustrated. 


BARTHOLOW'S  NEW  REMEDIES. — Preparing. 
New  Remedies  of  Indigenous  Source,  their  Physiological  Actions 

and  Therapeutical  Uses.  Edited  by  Roberts  Bartholow,  A.M.,  M.D.,  LL.D.,  Professor  of 
Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Medical  College  of  Philadelphia. 
In  one  octavo  volume  of  about  300  pages. 


EDES'  MATERIA  MEDIOA  AND  THERAPEUTICS.— In  Press. 
A  Text-Book  of  Materia  Medica  and  Therapeutics.    By  Kobert  T. 

Edes,  M.D.,  Jackson  Professor  of  Clinical  Medicine  in  Harvard  University.  In  one  octavo 
volume  of  about  600  pages,  with  illustrations. 


NETTLESHIP  ON  THE  EYE.— New  Edition.    In  Press. 
The  Student's  Guide  to  Diseases  of  the  Eye.  By  Edward  Nettleship, 

F.R.C.S.,  Ophthalmic  Surgeon  and  Lecturer  on  Ophthalmic  Surgery  at  St.  Thomas'  Hospital, 
London.  New  (3d  American  from  the  3d  English)  edition.  With  a  chapter  on  the  Detection 
of  Color-Blindness,  by  William  Thomson,  M.D.,  Ophthalmologist  to  the  Jefferson  Medical 
College.    In  one  royal  12mo.  volume  of  about  425  pages,  with  about  150  illustrations. 


GIBNEY'S  ORTHOPAEDIC  SURGERY.— Preparing. 

Orthopaedic  Surgery.  For  the  Use  of  Practitioners  and  Students.  By  V.  P. 
Gibney,  M.D.,  Surgeon  to  the  Orthopaedic  Hospital,  New  York,  etc.  In  one-handsome  octavo 
volume,  profusely  illustrated. 


COHEN  ON  THE  THROAT.— New  and  Revised  Edition.   In  Press. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diag- 
nosis and  Treatment  of  Affections  of  the  Pharynx, .  (Esophagus,  Trachea,  Larynx  and  Nares. 
By  J.  Solis-Cohen,  M.D.,  Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in 
the  Jefferson  Medical  College  of  Philadelphia.  Third  edition,  thoroughly  revised  and  rewritten, 
with  a  large  number  of  new  illustrations.    In  one  very  handsome  octavo  volume. 


HUTCHINSON  ON  SYPHILIS.— Shortly. 

Syphilis.  By  Jonathan  Hutchinson,  F.E.S.,  F.K.C.S.,  Consulting  Surgeon 
to  the  London  Hospital.    In  one  12mo  volume.    Series  of  Clinical  Manuals, 

BALL  ON  THE  RECTUM  AND  ANUS.— Preparing. 

Diseases  of  the  Rectum  and  Anus.  By  Charles  B.  Ball,  M.Ch.  Dub- 
lin, F.R.C.S.I.,  Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital.  In  one  12mo.  volume  of  about 
500  pages  with  4  colored  plates.    Shortly.    Series  of  Clinical  Manuals. 


NORRIS  AND  OLIVER'S  OPHTHALMOLOGY— Preparing. 

A  Text-book  of  Ophthalmology.  By  William  F.  Norkis,  M.D.,  Clinical 
Professor  of  Diseases  of  the  Eye  in  the  University  of  Pennsylvania,  and  Charles  A.  Oliver, 
M.D.    In  one  octavo  volume  of  about  500  pages,  with  illustrations. 


J8®*Full  detailed  catalogue  will  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


Volume  First,  Ready  in  a  Few  Days. 


THE 

American  Systems  of  Gynecology  and  Obstetrics. 

In  a  Series  of  Contributions  by  the  most  eminent 
American  Practitioners  and  Specialists. 

GYNECOLOGY  edited  by  Matthew  D.  Mann,  M.D., 

PROFESSOR  OF  OBSTETRICS  AND  GYNECOLOGY  IN  THE  VNIVERSITY  OF  BUFFALO,  N.  Tt. 

AND 

OBSTETRICS  edited  by  Barton  C.  Hirst,  M.D., 

OBSTETRICIAN  TO  THE  MATERNITY  AND  THE  PHILADELPHIA  HOSPITALS,  PHILADELPHIA. 

To  be  issued  in  four  very  handsome  royal  octavo  volumes  of  about  900  pages  each, 
prof  usely  illustrated  with  engravings  and  colored  plates.    Prices,  per  volume, 
cloth,  $5  ;  leather,  §6;  very  handsome  half  Russia,  raised  bunds,  $7. 
For  sale  by  subscription  only. 

The  profession  of  this  country  has  doubtless  learned  with  satisfaction  that  this  great  work 
is  now  in  such  a  stage  of  completion  that  the  first  volume  will  be  in  the  hands  of  its  readers  at 
an  early  date.  That  the  time  has  fully  arrived  for  the  preparation  of  such  a  work  is  shown  by 
the  readiness  with  which  the  foremost  men  of  this  country  have  engaged  to  contribute  under  a 
scheme  so  planned  as  to  call  forth  their  best  efforts.  Even  now,  before  the  first  volume  has 
appeared,  it  is  becoming  evident  that  the  profession  of  the  entire  world  will  welcome  this  latest 
product  of  American  authorship  with  at  least  as  much  warmth  as  was  bestowed  on  Pepper's 
System  of  Medicine  by  American  Authors. 


(Driret  Blank. 


No.  ;   _  188 

Messrs.  Lea  Brothers  &  Co., 

706  &  708  Sansom  St.,  Philadelphia. 
Please  enter  iny  name  on  your  books  as  a  subscriber  to 

The  American  Systems  of  Gynecology  and  Obstetrics, 

published  by  yourselves,  in  four  volumes,  at  dollars  per  volume, 

in   binding,  for  which  I  agree  to  pay  

dollars  upon  the  delivery  of  each  volume. 
I  Wish  the  Volumes  delivered  tcO 
me  on  the  dates  given  below  :    j  ^(jress 


Volume  I. 

II. 

"  III. 
"  IV. 


Prices  per  volume :  Cloth,  $5.00 ;  Leather,  $6.00  ;  Half  Russia,  $7.00.  Sub- 
scriptions received  for  the  complete  work  only. 


LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


IMPORTANT  RECENT  WORKS. 


A  SYSTEM  OF  PRACTICAL  MEDICINE. — By  American  Authors. 
Edited  by  William  Pepper,  M.D.,  LL.D.,  Provost  and  Professor  of 

the  Theory  and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of  Pennsyl- 
vania, assisted  by  Louis  Starr,  M.D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania.  The  complete  work,  in  five  volumes,  containing 
5573  pages,  with  198  illustrations,  is  now  ready.  Price  per  volume,  cloth,  $5.00;  leather,  $6.00  : 
half  Russia,  raised  bands  and  open  back,  $7.00.     For  sale  by  subscription  only. 


These  two  volumes  bring  this  admirable  work  to  a 
close,  and  fully  sustain  the  high  standard  reached  by 
the  earlier  volumes  ;  we  have  only,  therefore,  to  echo 
the  eulogium  pronounced  upon  them.  We  would 
warmly  congratulate  the  editor  and  his  collaborators 
at  the  conclusion  of  their  laborious  task  on  the  ad- 
mirable manner  in  which,  from  first  to  last,  they  have 
performed  their  several  duties.    They  have  succeeded 


in  producing  a  work  which  will  long  remain  a  stan- 
dard work  of  reference,  to  which  practitioners  will 
look  for  guidance,  and  authors  will  resort  to  for  facts. 
From  a  literary  point  of  view,  the  work  is  without 
any  serious  blemish  ;  and  in  respect  of  production,  it 
has  the  beautiful  finish  that  Americans  always  give 
their  works. — Edinburgh  Medical  Journal,  January, 
1887. 


FLINT'S  PRACTICE. 

New  (Sixth)  Edition.   Now  Ready. 
A  Treatise  on  the  Principles  and  Practice  of  Medicine.    Designed  for 

the  Use  of  Practitioners  and  Students  of  Medicine.  By  Austin  Flint,  M.D.,  LL.D.,  Late  Pro- 
fessor of  the  Principles  and  Practice  of  Medicine  and  of  Clinical  Medicine  in  Bellevue  Hos- 
pital Medical  College,  New  York.  New  (sixth)  edition,  thoroughly  revised  and  rewritten  by 
the  author,  assisted  by  William  H.  "Welch,  M.D.,  Professor  of  Pathology,  Johns  Hopkins 
University,  Baltimore,  and  Austin  Flint,  Jr.,  M.D.,  LL.D.,  Professor  of  Physiology,  Bellevue 
Hospital  Medical  College,  New  York.  In  one  very  handsome  octavo  volume  of  1170  pages, 
with  illustrations.   Cloth,  $5.50  :  leather,  $6.50  ;  very  handsome  half  Russia,  raised  bands,  $7.00. 

A  new  edition  of  a  work  of  such  established  reputa-  he  has  left  behind  him.    It  has  few  equals,  either  in 

tion  as  Flint's  Medicine  needs  but  few  words  to  com-  point  of  literary  excellence,  or  of  scientific  learning, 

mend  it  to  notice.    It  may  in  truth  be  said  to  embody  and  no  one  can  fail  to  study  its  pages  without  being 

the  fruit  of  his  labors  in  clinical  medicine,  ripened  by  struck  by  the  lucidity  and  accuracy  which  character  - 

the  experience  of  a  long  life  devoted  to  its  pursuit,  ize  them.    It  is  qualities  such  as  these  which  render 

America  may  well  be  proud  of  having  produced  a  man  it  so  valuable  for  its  purpose,  and  give  it  a  foremost 

whose  indefatigable  industry  and  gifts  of  genius  have  place  among  the  text-books  of  this  generation. — The 

done  so  much  to  advance  medicine  ;  and  all  English-  :  London  Lancet,  March  12,  1887. 
reading  students  must  be  grateful  for  the  work  which  ' 


THE  AMERICAN  SYSTEM  OF  DENTISTRY. 

Third  and  Final  Volume  Shortly 
In  Treatises  by  Various  Authors.    Edited  by  Wilbur  F.  Litch,  M.D., 

D.D.S.,  Professor  of  Prosthetic  Dentistry,  Therapeutics  and  Materia  Medica  in  the  Pennsylvania 
College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  of  about  1000  pages  each, 
richly  illustrated.    Per  volume,  cloth,  $6  :  leather,  $7  ;  half  morocco,  gilt  top,  $8.    For  sale  by 

subscription  only. 


Nowhere  else  can  be  found  such  a  faithful  exposi- 
tion of  the  present  status  of  American  dentistry,  and 
those  of  us  who  have  grown  rusty,  as  well  as  the  live 
practitioner  and  student  will  find  here  ample  food  for 
study  and  improvement.  —  The  Ohio  State  Journal  of 
Dental  Science,  May  1, 1887. 

The  examination  of  the  second  volume  of  this  in- 
comparable work  strengthens  the  favorable  opinion 
we  had  formed  on  the  appearance  of  its  first  volume. 
It  is  our  purpose  to  give  hearty  endorsement  of  the 
volumes  so  far  issued,  feeling  that  the  remaining  vol- 
ume will  complete  in  a  masterly  manner  the  work  so 
well  carried  forward  in  the  volumes  before  us.  Volume 


II.  will  be  especially  interesting  and  valuable  to  prac- 
titioners and  students,  as  it  is  devoted  to  the  daily 
work  of  the  profession,  giving  all  that  is  latest  and 
best  in  the  several  departments. — TJie  Dental  Eclectic. 
March,  1887. 

As  would  naturally  be  expected  in  a  work  of  this 
size  and  scope,  everything  that  pertains  to  the  two 
fields  of  dental  practice  finds  a  place  for  consideration. 
It  is  a  work  fully  up  to  the  times,  and  is  in  itself  an 
encyclopaedia  of  dental  knowledge.  The  second  vol- 
ume is  full  of  practical  siiggestions  and  valuable  in- 
formation for  both  old  and  young  practitioners. — The 
Cincinnati. Medical  and  Dental  Journal,  March,  1887. 


457*  Eull  descriptive  catalogue,  free  to  any  address  on  application  to 

LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


LEA  BROTHERS  &  CO; S  MEDICAL  AND  SURGICAL  PUBLICATIONS. 
NEW  (FOURTH)  EDITION. — NOW  READY. 

THE  NATIONAL  DISPENSATORY. 

Containing  the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of 
Medicines,  including  those  recognized  in  the  Pharmacopoeias  of  the  United  States,  Great 
Britain  and  Germany,  with  numerous  references  to  the  French  Codex.  By  Alfred  Stille, 
M.D.,  LL.D.,  Professor  Emeritus  of  Theory  and  Practice  of  Medicine  and  of  Clinical  Medicine 
in  the  University  of  Pennsylvania,  and  John  M.  Maisch,  Phar.D.,  Professor  of  Materia  Medica 
and  Botany  in  the  Philadelphia  College  of  Pharmacy,  Secretary  to  the  American  Pharmaceu- 
tical Association.  Fourth  edition,  revised  to  October,  1886,  and  covering  the  new  British 
Pharmacopoeia.  In  one  magnificent  imperial  octavo  volume  of  1794  pages,  with  311  elaborate 
engravings.  Price  in  cloth,  $7.25 ;  leather,  raised  bands,  $8.00 ;  very  handsome  half  Russia, 
raised  bands  and  open  back,  $9.00.  Patent  Ready  Reference  Thumb-letter  Index,  $1  in  addi- 
tion to  price  in  any  of  above  styles  of  binding. 


We  think  it  a  matter  for  congratulation  that  the 
profession  of  medicine  and  that  of  pharmacy  have 
shown  such  an  appreciation  of  this  great  work  as  to 
call  for  four  editions  within  the  comparatively  brief 
period  of  eight  years.  The  matters  with  which  it  deals 
are  of  so  practical  a  nature  that  neither  the  physician 
nor  the  pharmaceutist  can  do  without  the  latest  text- 
books on  them,  especially  those  that  are  so  accurate 
and  comprehensive  as  this  one.  The  book  is  in  every 
way  creditable,  both  to  the  authors  and  to  the  publish- 
ers.— New  York  Medical  Journal,  May  21,  1887. 

The  National  Dispensatory  is  so  well  and  favorably 
known  on  both  sides  of  the  Atlantic  that  scarcely 
anything  is  left  to  the  reviewer,  except  to  call  atten- 


tion to  the  fact  that  another  edition  of  this  valuable 
work  has  made  its  appearance.  This  last  edition  sur- 
passes even  its  predecessors  in  thoroughness  and  accu- 
racy. The  fact  that  in  1884,  when  the  third  edition 
was  published,  no  revision  of  the  British  Pharma- 
copoeia had  been  made  for  seventeen  years,  has  neces- 
sitated a  thorough  going  over  of  the  whole  work  in 
order  that  references  might  correspond  to  the  last  re- 
vision of  the  work  of  our  British  cousins.  In  addition 
to  these  changes  is  a  fairly  full  resume,  in  the  form 
of  addenda,  of  the  more  important  drugs  which  have 
come  into  general  use  in  the  last  two  or  three  years. 
— American  Journal  of  the  Medical  Sciences,  April,  1887 . 


SMITH'S  OPERATIVE  SURGERY.— New  and  Thoroughly  Revised 
Edition.   Now  Ready. 
The  Principles  and  Practice  of  Operative  Surgery.    By  Stephen 

Smith,  M.D.,  Professor  of  Clinical  Surgery  in  the  University  of  the  City  of  New  York  :  Visiting 
Surgeon  to  Bellevue  and  St.  Vincent's  Hospitals.  New  (second)  and  thoroughly  revised 
edition.  In  one  very  handsome  octavo  volume  of  S92  pages,  with  1005  illustrations.  Cloth, 
$4;  leather,  $5. 

Even  since  1879  surgery  has  changed  so  much  as  this  the  best  as  it  is  the  most  comprehensive  book  of 
well  to  deserve  the  epithet  "new."  Almost  every-  its  kind  in  the  language  Many  of  the  illustrations 
thing  which  has  helped  to  bring  about  this  change  has  were  made  for  it,  and  the  paper  and  type  are  pleasant 
been  incorporated.  One  can  scarcely  think  of  any  to  the  eye.  Dr.  Smith  has  writteu  that  which  reflects 
operation  of  the  present  day,  however  minute,  which  immense  credit,  not  only  upon  himself  but  upon  the 
he  cannot  find  here  described.    Altogether  we  esteem    American  profession. — The  Medical  Press,  May,  1887 


PARVIN'S  OBSTETRICS.— Now  Ready. 
The  Science  and  Art  of  Obstetrics.    By  Theophiltjs  Paryix,  M.D., 

LL.D.,  Professor  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  the  Jefferson 
Medical  College  of  Philadelphia.  In  one  very  handsome  octavo  volume  of  697  pages,  with  214 
illustrations  and  a  colored  plate.    Cloth,  $4.25;  leather,  $5.25. 

To  say  that  this  work  is  a  complete  exposition  of  the  records,  has  escaped  his  notice.    The  book  is  written 

science  and  art  of  obstetrics  as  at  present  practised  by  in  a  didactic  style,  as  might  be  expected  of  one  who 

the  most  enlightened  physiciaus  of  the  world,  is  but  for  a  quarter  of  a  century  has  been  a  teacher,  but  this 

telling  the  exact  truth  in  regard  to  it.    Scarcely  an  style  well  befits  the  subject.    The  illustrations  arc 

item  relating  to  midwifery,  which  is  of  any  real  value  particularly  good. — St.  Louis  Medical  atid  Surgical  Jour- 

and  which  may  be  considered  an  advance  in  or  a  con-  nal,  May,  1887. 
tribution  to  the  knowledge  gleaned  by  centuries  of 


BARTHOLOW  ON  ELECTRICITY.— Third  Edition.    Just  Ready. 

Medical  Electricity.  A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.  By  Roberts  Bartholow,  A.M.,  M.D.,  LL.D.,  Professor  of  Materia 
Medica  and  General  Therapeutics  in  the  Jefferson  Medical  College  of  Philadelphia,  etc.  New 
(third)  edition.  In  one  very  handsome  octavo  volume  of  308  pages,  with  110  illustrations. 
Cloth,  $2.50. 

This  book  has  been  long  enough  before  the  public  to  therapeutic  agent.  The  additions  to  this  edition  have 
be  well  known.  Electricity,  its  nature  and  modes  of  been  chiefly  in  the  sections  on  therapeutics.  Without 
manifestation  are  first  considered,  then  the  means  of  doubt  this  edition  will  maintain  the  popularity  of  the 
generating  it,  later  electro-physiology,  or  its  physio-  work. — Journal  of  the  American  Medical  Association, 
logical  action,  and  finally  its  use  as  a  diagnostic  and    June  11,  1887. 


Full  descriptive  catalogue  trill  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


LEA  BROTHERS  &  CO.' 6'  MEDICAL  AND  SURGICAL  PUBLICATIONS. 


FOTHERGILL' S  HANDBOOK  OF  TREATMENT.— New  Edition. 
The  Practitioner's  Handbook  of  Treatment ;  or,  The  Principles  of 

Therapeutics.  By  J.  Milner  Fothergill,  M.D.  Edin.,  M.R.C.P.  Lond.,  Physician  to  the 
City  of  London  Hospital  for  Diseases  of  the  Chest.  New  (third)  edition.  In  one  octavo 
volume  of  661  pages.    Cloth,  $3.75  :  leather,  $4.75.    Just  ready. 

To  one  conversant  with  the  medical  literature  of  the  chapter,  and  the  relations  between  the  two  clearly 
last  twenty  years  few  names  are  more  familiar  than  stated  cannot  fail  to  prove  a  great  convenience  to 
that  of  Fothergill.  He  has  often  addressed  the  pro-  many  thoughtfu1  but  busy  physicians.  Few  men  can 
fession,  not  only  through  the  periodicals,  but  also  in  read  the  book  carefully  without  being  benefited  there- 
pamphlets  and  books.  Particularly  to  young  phys-  by.  That  the  profession  appreciates  that  the  author 
icians  have  his  messages  been  frequent  and  instructive,  i  has  undertaken  an  important  work,  and  has  accom- 
To  have  a  description  of  the  normal  physiological  |  plished  it  with  a  reasonable  degree  of  success,  is 
processes  of  an  organ  and  of  the  methods  of  treatment  j  amply  shown  by  the  demand  for  this  third  edition.  — 
of  its  morbid  conditions  brought  together  in  a  single  '  New  York  Medical  Journal,  June  11,  1887. 


BRUNTON'S  MATERIA  MEDIO  A  AND  THERAPEUTICS. 
A  Text-book  of  Pharmacology,  Therapeutics  and  Materia  Medica. 

By  T.  Lauder  Brunton,  M.D.,  D.Sc,  F.R.C.P.,  F.R.S.,  Lecturer  on  Materia  Medica  at  St.  Bar- 
tholomew's Hospital ;  Examiner  in  Materia  Medica  in  the  University  of  London,  in  the  Victoria 
University,  and  in  the  Royal  College  of  Physicians,  London.  Adapted  to  the  United  States 
Pharmacopoeia,  by  Francis  H.  Williams,  M.D.,  Boston,  Mass.  One  large  octavo  volume  of 
1033  pages,  with  188  illustrations.  Cloth,  $5.50;  leather,  $6.50. 
Of  all  the  numerous  publications  of  this  year  upon  |  hensive  manner  upon  the  foundation  principles  of  the 


the  subject  of  Pharmacology  the  comprehensive  work 
of  Brunton  is  clearly  the  most  important,  and  is  be- 
yond question  the  foremost  English  handbook  of 
Materia  Medica  and  Therapeutics  since  the  appear-" 
ance  of  Pereira's  Elements  of  Materia  Medica  in  1842. 
It  is  original  both  in  the  arrangement  of  the  subjects 
and  in  the  mode  of  treatment,  and  builds  in  a  compre- 


science  of  Pharmacology,  without  leaving  the  needs 
of  the  practitioner  out  of  sight  for  an  instant.  In  fact, 
the  author  has  written  a  book  which  deserves  to  be 
known  far  beyond  the  boundaries  of  England,  and  can 
serve  as  a  model  for  the  pharmacological  works  of  the 
continent  on.  account  of  its  happy  combination  of 
theory  with  practice. — Virchow's  Jahresb.,  Berlin,  1886. 


EMMET'S  GYNAECOLOGY.— Third  Edition. 


The  Principles  and  Practice  of  Gynecology.     By  Thomas  Addis 

Emmet,  M.D.,  LL.D.,  Surgeon  to  the  Woman's  Hospital,  New  York,  etc.  New  (third)  edition, 
thoroughly  revised.  In  one  large  and  very  handsome  octavo  volume  of  850  pages,  with  150 
illustrations.    Cloth,  $5.00:  leather,  $6.00. 


"We  are  in  doubt  whether  to  congratulate  the  author 
more  than  the  profession  upon  the  appearance  of  the 
third  edition  of  this  well-known  work.  Embodying, 
as  it  does,  the  life-long  experience  of  one  who  has 
conspicuously  distinguished  himself  as  a  bold  and 
successful  operator,  and  who  has  devoted  so  much 
attention  to  the  specialty,  we  feel  sure  the  profession 


will  not  fail  to  appreciate  the  privilege  thus  offered 
them  of  perusing  the  views  and  practice  of  the  author. 
His  earnestness  of  purpose  and  conscientiousness  are 
manifest.  He  gives  not  only  his  individual  expe- 
rience but  endeavors  to  represent  the  actual  state  of 
gynaecological  science  and  art. — British  Medical  Jour- 
nal, May  ltf,  1885. 


GROSS  ON  IMPOTENCE. — New  (Third)  Edition.    Just  Beady. 
A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 

of  the  Male  Sexual  Organs.  By  Samuel  W.  Gross,  A.M.,  M.D.,  LL.D,  Professor  of  the  Prin- 
ciples of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
New  ( third)  edition,  thoroughly  revised.  In  one  very  handsome  octavo  volume  of  163  pages, 
with  16  illustrations.    Cloth,  $1.50. 

It  must  be  gratifying  to  both  author  and  publishers  study  of  the  sexual  act,  so  far  as  it  concerns  the  male, 
that  large  first  and  second  editions  of  this  little  work  and  all  his  conclusions  are  scientifically  reached.  The 
were  so  soon  exhausted,  while  the  fact  that  it  has  book  has  a  place  by  itself  in  our  literature  and  fur- 
been  translated  into  Russian  may  indicate  that  it  has  nishes  a  large  fund  of  information  concerning  un- 
filled a  void  even  in  foreign  literature.  On  every  page  portant  matters  that  are  too  often  passed  over  in 
the  author  has  shown  how  diligent  a  student  he  is  of  silence.  —  The  Medical  Press,  June,  1887. 
foreign  literature.    His  is  a  careful  and  physiological 


PL  A  YP  AIR'S  MIDWIFERY. — New  (Fourth)  Edition. 
A  Treatise  on  the  Science  and  Practice  of  Midwifery.    By  W.  S. 

Playfair,  M.D.,  F.R.C.P.,  Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc* 
New  (fourth)  American  from  the  fifth  English  edition.  Edited,  with  additions,  by  Robert 
P.  Harris,  M.D.  In  one  handsome  octavo  volume  of  653  pages,  with  3  plates  and  201  engrav- 
ings.   Clotb,  $4.00;  leather,  $5.00;  half  Russia,  $5.50. 

This  classic  work,  since  its  first  appearance  in  1876,  be  sought,  it  will  be  found  in  the  fact  that  he  has  mas- 
has  steadily  gained  in  professional  favor,  until  now  it  tered  the  art  of  condensed  writing,  that  he  is  endowed 
is  a  standard  text-book  in  English  and  American  col-  in  large  measure  with  common  sense,  and  that  he  ap- 
leges,  and  the  indispensable  companion  of  the  work-  proaches  every  topic  from  the  side  of  the  clinician.— 
ing  practitioner.    If  the  secret  of  the  author's  success    Louisville  Medical  News,  November  7, 1885. 


/S^Full  descriptive  catalogue  will  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  <fe  CO.,  Publishers,  Philadelphia. 


LEA  BROTHERS  &  CO.'S  MEDICAL  AND  SURGICAL  PUBLICATIONS. 


SMITH  ON  CHILDREN.— Sixth  Edition. 
A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.    By  J.  Lewis 

Smith,  M.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical 
College,  New  York.  New  (sixth)  edition,  thoroughly  revised  and  rewritten.  In  one  handsome 
octavo  volume  of  867  pages,  with  illustrations.    Cloth,  $1.50 ;  leather,  $5,50  j  half  Russia,  $6.00. 


Dr.  Smith's  work  has  justly  become  the  standard 
authority  all  over  the  world  as  the  book  on  children's 
diseases.  This  sixth  edition  is  so  thoroughly  revised 
that  we  can  scarcely  refer  to  an  advance  in  the  depart- 
ment of  pediatrics  within  the  past  few  years  that  has 
been  announced  in  the  journals  which  is  not  discussed 
in  these  pages.  The  whole  book  is  admirable,  both 
for  the  practitioner  and  student.  Dr.  Smith  writes 
from  a  large  experience  and  a  close  observation  of 


cases  at  the  bedside.  He  is  extremely  practical,  and 
these  facts  make  the  work  what  it  ought  to  be,  the 
best  of  all  works  on  the  diseases  of  children.  It 
needs  no  commendation  from  our  pen ;  the  simple 
announcement  of  the  publication  of  a  thoroughly  re- 
vised edition,  which  is  finely  indexed  and  handsomely 
issued  will  prove  sufficient. — Virginia  Med.  3Tonthly, 
June;  1886. 


RICHARDSON'S  PREVENTIVE  MEDICINE. 
Preventive  Medicine.   By  B.  W.  Richardson,  M.A.,  M.D.,  LL.D.,  F.R.S., 

F.S.A.  Fellow  of  the  Royal  College  of  Physicians,  London.  In  one  handsome  octavo  volume 
of  729  pages.    Cloth,  $4.00 ;  leather,  $5.00  ;  half  Russia,  raised  bands,  $5.50. 

handles  his  numerous  and  varied  subjects  with  such 
power  and  skill,  that  he  commands,  in  an  unusual 
degree,  the  attention  and  interest  of  the  reader.  His 
style  is  simple,  always  clear,  often  vigorous.  He 
never  descends  to  the  use  of  needless  technicalities, 
never  makes  rash  and  extravagant  statements.  The 
book  is  really  just  what  it  claims  to  be,  and  yet  some- 
thing better.  It  will  be  read  and  appreciated  by 
physicians  wherever  the  English  language  is  spoken, 
and  cannot  but  add  new  lustre  to  Dr.  Richardson's 
already  brilliant  reputation  as  a  teacher,  author  and 
philosopher. — American  Practitioner,  July,  1884. 


It  excels  any  other  book  which  has  fallen  under 
our  observation  on  the  subject  of  which  it  treats.  It 
comprehends  the  nature,  causes  and  prevention  of 
disease  from  a  strictly  scientific  standpoint.  It  con- 
tains much  with  which  every  physician  should  be 
familiar.  There  is  no  other  work  in  the  language  in 
which  the  information  here  presented  can  be  found  so 
systematically  arranged  and  intelligently  presented. 
—The  Sanitarian,  March,  1884. 

The  plan  of  it  embraces,  as  indicated  by  the  title, 
the  whole  field  of  disease.  It  is  vast  in  its  scope, 
yet  the  arrangement  is  so  admirable,  and  the  author 


PURDY  ON  BRIGHT' S  DISEASE  AND  KIDNEY  AFFECTIONS. 
Bright's  Disease  and  Allied  Affections  of  the  Kidneys.    By  Charles 

W.  Purdy,  M.D.    In  one  octavo  volume  of  288  pages,  with  illustrations.  Cloth,  $2, 


The  author  of  this  book  is  well  known  to  our  read- 
ers as  a  careful  investigator  and  conscientious  student 
of  renal  diseases.  His  object  in  writing  the  book  is 
to  furnish  a  systematic,  practical  and  concise  descrip- 
tion of  the  pathology  and  treatment  of  the  chief  or- 
ganic diseases  of  the  kidneys  associated  with  albumin 
uria,  which  shall  represent  the  most  recent  advances 
in  our  knowledge  on  these  subjects.    Dr.  Purdy  has 


accomplished  his  object,  and  has  given  the  profession 
a  valuable  work  on  this  class  of  disorders.  There  is  a 
positiveness  of  style  employed  that  lends  assurance 
and  confidence  to  the  reader.  No  physician  can  read 
Dr.  Purdy'swork  without  feeling  better  fortified  and 
qualified  to  meet  these  common  yet  formidable  dis- 
eases.— The  Physician  and  Surgeon,  May,  1887. 


ROBERTS  ON  URINARY  DISEASES.— Fourth  Edition. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including 
Urinary  Deposits.  By  William  Roberts,  M.D.,  Lecturer  on  Medicine  in  the  Manchester 
School  of  Medicine,  etc.  Fourth  American  from  the  fourth  London  edition.  In  one  handsome 
octavo  volume  of  609  pages,  with  81  illustrations.    Cloth,  $3.50. 


The  appearance  of  a  new  edition  of  Dr.  Roberts' 
well-known  and  valuable  work  is  an  event  which  will 
be  hailed  with  pleasure  by  all  who  are  familiar  with 
the  last  edition,  for  all  are  naturally  anxious  to  ascer- 
tain the  views  of  so  mature  an  observer,  and  so  busy 
a  physician  on  so  practical  a  subject.   Maintaining,  as 


it  does,  the  merits  of  previous  editions,  with  those 
improvements  demanded  by  more  recent  accessions  to 
our  knowledge,  we  predict  for  the  volume  the  success 
of  its  predecessors. — The  American  Journal  of  the  Medi- 
cal Sciences,  April,  1886. 


ROSS  ON  NERVOUS  DISEASES.— Just  Ready. 
A  Handbook  on  Diseases  of  the  Nervous  System.    By  James  Ross, 

M.D.,  F.R.C.P.,  LL.D.,  Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary.  In 

one  handsome  octavo  volume  of  725  pages,  with  184  illustrations.    Cloth,  $4.50;  leather,  $5.50. 

The  special  and  peculiar  leature  of  this  book  is  that  [  neurological  library,  aud  to  every  complete  practical 
it  describes  not  only  the  classical  diseases  of  the  nerv-  collection  of  medical  literature.  The  scope  and  execu- 
ous  system  more  than  any  other  book,  but  it  describes  '  tion  of  the  book  far  exceed  the  modest  pretensions  of 
those  morbid  conditions  of  the  brain,  cord,  meninges,  ]  its  author  as  set  forth  in  the  preface.  The  illustrations 
ganglia  and  nerves,  which  have  not  been  generally  are  singularly  well  selected  for  clear  elucidation  of 
recognized  by  neurologists  as  morbid  entities,  and  j  the  respective  texts  which  they  accompany. — The 
must  therefore  be  an  indispensable  addition  to  every  |  Alienist  and  Neurologist,  January,  18Sl>. 


4®*  Full  descriptive  catalogue  will  be  found  at  tlte  end  of  this  volume. 

LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia 


LEA  BROTHERS  &  CO.'S  MEDICAL  AND  SURGICAL  PUBLICATIONS. 


ASHHUBST'S  SURGERY.— Fourth  Edition. 
The  Principles  and  Practice  of  Surgery.    By  John  Ashhurst,  Jr., 

M.D.,  Professor  of  Clinical  Surgery  in  the  University  of  Pennsylvania,  Surgeon  to  the  Episcopal 
Hospital,  Philadelphia.  Fourth  edition,  enlarged  and  revised.  In  one  large  and  handsome 
octavo  volume  of  1114  pages,  with  597  illustrations.  Cloth,  $6.00;  leather,  $7. 00;  half  Russia,  $7.50. 

As  with  Erichsen  so  with  Ashhurst,  its  position  in  |  and  better  illustrated  than  before,  and  its  author  may 
professional  favor  is  established,  and  one  has  now  but  j  rest  assured  that  it  will  certainly  have  a  "continuance 
to  notice  the  changes  if  any,  in  theory  and  practice,  I  of  the  favor  with  which  it  has  heretofore  been  re- 
that  are  apparent  in  the  present  as  compared  with  the  j  ceived." — The  American  Journal  of  the  Medical  Science*, 
preceding  edition,  published  three  years  ago.  The  i  January,  1886. 
work  has  been  brought  well  up  to  date,  and  is  larger  j 


GROSS'  SYSTEM  OF  SURGERY. — Sixth  Edition. 

A  System  of  Surgery;  Pathological,  Diagnostic,  Therapeutic  and 

Operative.  By  Samuel  D.  Gross,  M.D.,  LL.D.,  D.C.L.  Oxon.,  LL.D.  Cantab.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia.  Sixth  edition,  thoroughly 
revised  and  greatly  improved.  In  two  large  and  beautifully  printed  imperial  octavo  volumes 
containing  2382  pages,  illustrated  by  1623  engravings.  Strongly  bound  in  leather,  raised  bands, 
$15.00  ;  half  Russia,  raised  bands,  $16.00. 

His  System  of  Surgery,  which,  since  its  first  edition  j  men  in  other  countries,  and  how  much  he  contributed 
in  1859,  has  been  a  standard  work  in  this  country  as  I  to  promote  the  science  and  practice  of  surgery  in  his 
well  as  in  America,  in  "the  whole  domain  of  surgery,"  i  own.  There  has  been  no  man  to  whom  America  is  so 
tells  how  earnest  and  laborious  and  wise  a  surgeon  he  :  much  indebted  in  this  respect  as  the  Nestor  of  surgery, 
was,  how  thoroughly  he  appreciated  the  work  done  by  I  —  British  Medical  Journal,  May  10,  1884. 


BARNES'  OBSTETRIC  MEDICINE  AND  SURGERY. 
A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and 

Clinical.  For  the  Student  and  the  Practitioner.  By  Robert  Barnes,  M.D.,  Physician  to  the 
General  Lying-in  Hospital,  London,  and  Fancourt  Barnes,  M.D.,  Obstetric  Physician  to  St. 
Thomas'  Hospital,  London.  The  Section  on  Embryology  contributed  by  Prof.  Milnes  Mar- 
shall. In  one  handsome  octavo  volume  of  872  pages,  with  231  illustrations.  Cloth,  $5.00; 
leather,  $6.00. 


This  system  will  be  eagerly  sought  for,  not  only  on 
account  of  its  intrinsic  merit,  but  also  because  the 
reputation  which  the  elder  Barnes  in  particular  has 
secured,  carries  with  it  the  conviction  that  any  book 
emanating  from  him  is  necessarily  sound  in  teaching 
and  conservative  in  practice.  It  is,  indeed,  eminently 
fitting  that  a  man  who  has  done  so  much  toward  sys- 
tematizing the  obstetric  art,  who  for  so  many  years 
has  been  widely  known  as  a  capable  teacher  and 


trusted  accoucheur,  should  embody  within  a  single 
treatise  the  system  which  he  has  taught  and  in  prac- 
tice tested,  and  which  is  the  outcome  of  a  lifetime  of 
earnest  labor,  careful  observation,  and  deep  study. 
The  result  of  this  arrangement  is  the  production  of  a 
work  which  rises  above  criticism  and  which  in  no  re- 
spect need  yield  the  palm  to  any  obstetrical  treatise 
hitherto  published. — American  Journal  of  Obstetrics, 
February,  1886. 


PINLAYSON'S  CLINICAL  DIAGNOSIS.— New  Edition. 
Clinical  Manual  for  the  Study  of  Medical  Cases.    With  Chapters  by 

Prof.  Gairdner  on  the  Physiognomy  of  Disease;  Prof.  Stephenson  on  Diseases  of  the  Female 
Organs  ;  Dr.  Robertson  on  Insanity  ;  Dr.  Gemmell  on  Physical  Diagnosis  ;  Dr.  Coats  on  Laryn- 
goscopy and  Post-mortem  Examinations,  and  by  the  Editor  on  Case-taking,  Family  History 
and  Symptoms  of  Disorder  in  the  Various  Systems.  Edited  by  James  Finlayson,  M.D.,  Phys- 
ician and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc.  New  edition. 
In  one  12mo.  volume  of  682  pages,  with  158  illustrations.    Cloth,  $2.50. 


This  is  a  work  which  every  physician,  young  and 
old,  will  find  most  useful.  Its  object  is  to  aid  in 
making  diagnoses,  and  consequently  it  describes  and 
treats  of  all  the  various  symptoms  which  are  exhibited 
in  the  progress  of  disease — their  importance,  indica- 


tions, etc.  Although  comparatively  a  small  work,  it 
is  replete  with  information  of  the  most  practical  char- 
acter upon  all  subjects  pertaining  to  diagnosis. — Cin- 
cinnati Medical  News,  March,  1887. 


HAMILTON  ON  FRACTURES  AND  DISLOCATIONS. 

A  Practical  Treatise  on  Fractures  and  Dislocations.    By  Frank  H. 

Hamilton,  M.D.,  LL.D.,  Surgeon  to  Bellevue  Hospital,  New  York.  Seventh  edition,  thor- 
oughly revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998  pages,  with 
379  illustrations.    Cloth,  $5.50;  leather,  $6.50 :  very  handsome  half  Russia,  open  back,  $7.00. 


In  this  revised  edition  of  his  classical  work  on  frac-  [ 
tures  and  dislocations,  Professor  Hamilton  has  in- 
cluded notices  of  most  recent  contributions  to  the 
literature  of  these  subjects.  In  this,  as  in  former 
editions,  it  will  be  found  that  the  author  has  at- 
tempted not  only  to  collect  information  from  every 
available  source,  but  also  to  render  such  information 
reliable  by  a  constant  effort  to  eliminate  doubtful 
statements.    This  work,  which,  since  its  first  appear- 


ance twenty-five  years  ago,  has  gone  through  many 
editions,  may  now  be  fairly  regarded  as  the  authorita- 
tive book  of  reference  on  the  subject  of  fractures  and 
dislocations.  Each  successive  edition  has  been  ren- 
dered of  greater  value  through  the  addition  of  more 
recent  work,  and  especially  of  the  recorded  researches 
and  improvements  made  by  the  author  himself,  and 
by  his  countrymen. — British  Medical  Journal,  May  9, 
1885. 


FuU  descriptive  catalogue  will  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


LEA  BROTHERS  &  CO: S  MEDICAL  AJSJD  SURGICAL  PUBLICATIONS. 


HART SHORNE ' S  HOUSEHOLD  MEDICINE. 
A  Household  Manual  of  Medicine,  Surgery,  Nursing  and  Hygiene, 

for  Daily  Use  in  the  Preservation  of  Health  and  Care  of  the  Sick  and  Injured ;  with  an  Intro- 
ductory Outline  of  Anatomy  and  Physiology.  By  Henry  Hartshorne,  A.M.,  M.D.,  LL.D., 
formerly  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  and  Professor  of  Physiology 
and  Diseases  of  Children  in  the  Woman's  Medical  College  of  Pennsylvania.  In  one  very  hand- 
some royal  octavo  volume  of  946  pages,  with  8  plates  and  283  engravings.  Cloth,  $4.00 ; 
very  handsome  half  Morocco,  $5.00. 

It  is  the  province  of  the  physician  not  only  to  care  for  actual  disease,  but  to  use  all  means  to 
preserve  the  well-being  of  the  community.  In  no  way  can  he  perform  this  duty  more  efficiently 
than  by  placing  in  the  hands  of  his  patients  the  work  above  mentioned.  Coming  from  the  pen 
of  a  physician  thoroughly  versed  in  the  science  of  his  profession  and  in  the  art  of  clear  and 
simple  exposition,  it  instructs  the  laity  on  points  which  they  should  know,  without  trenching 
on  the  prerogatives  of  medical  men,  and  is  thus  well  calculated  to  save  the  public  as  well  as  the 
legitimate  profession  from  the  greatest  enemy  of  both — the  quack. 


By  the  same  Author. 
Essentials  of  the  Principles  and  Practice  of  Medicine.    A  Handbook 

for  Students  and  Practitioners.  Filth  edition,  thoroughly  revised  and  much  improved.  In 
one  handsome  royal  12mo.  volume  of  669  pages,  with  144  illustrations.  Cloth,  $2.75;  half 
bound,  $3.00. 

We  cannot  speak  too  highly  of  this  hrief  epitome  I  this  book  to  students  and  practitioners. — Canada 
Of  medicine.    It  is  a  masterpiece  of  condensation.    Lancet,  April,  1882. 

Many  new  additions  have  been  made  throughout  the  Hartshorne's  Essentials  is  certainly  the  best  hand- 
work, some  new  subjects  written  upon,  and  a  new  book  of  general  practice  tbat  we  have  seeD,  and  will 
section  is  added  upon  eyesight,  its  examination  and  be  of  value  to  both  the  classes  for  whom  it  is  intended, 
correction.  We  have  much  pleasure  in  recommending    — St.  Louis  Courier  of  Medicine,  April,  1882. 


BUMSTBAD  AND  TAYLOR  ON  VENEREAL.— Fifth  Edition. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  By  Freeman  J.  Bumstead,  M.D.,  LL.D., 
late  Professor  of  Venereal  Diseases  at  the  College  of  Physicians  and  Surgeons,  New  York,  etc.  ; 
and  Robert  W.  Taylor,  A.M.,  M.D.,  Surgeon  to  Charity  Hospital,  New  York,  Professor  of 
Venereal  and  Skin  Diseases  in  the  University  of  Vermont,  President  of  the  American  Derma- 
tological  Association.  Fifth  edition,  revised  and  largely  rewritten,  by  Dr.  Taylor.  In  one 
large  and  handsome  octavo  volume  of  898  pages,  with  139  illustrations,  and  13  chromo-litho- 
graphic  figures.    Cloth,  $4.75  ;  leather,  $5.75;  very  handsome  half  Russia,  $6.25. 

We  admire  the  work  as  the  most  comprehensive  1     It  is  certainly  the  best  single  treatise  on  venereal  in 
and  exhaustive  treatise  which  has  yet  been  written  |  our  own  and  probably  the  best  in  any  language. — 
<ipon  venereal  diseases. — Dublin  Journal  of  Medical  Sci-  I  Boston  Medical  and  Surgical  Journal.  April  3,  1884. 
ence,  April,  1884. 


BURNETT  ON  THE  EAR.— Second  Edition. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  By  Charles  H.  Burnett,  A.M.,  M.D.,  Pro- 
fessor of  Otology  in  the  Philadelphia  Polyclinic;  President  of  the  American  Otological  Society. 
Second  edition.  In  one  handsome  octavo  volume  of  580  pages,  with  107  illustrations.  Cloth, 
$4.00 ;  leather,  $5.00. 

We  are  glad  to  welcome  the  second  edition  of  this  work  consists  of  a  clear  and  terse  account  of  the  dis- 
excellent  text-book  to  our  shelves.  The  first  part  is  eases  of  the  ear  and  their  treatment.  In  the  latter 
devoted  to  a  lucid  account  of  the  anatomy,  histology,  department  the  rules  laid  down  are  eminently  prac- 
and  physiology  of  this  most  complex  organ.  The  cuts  tical.  We  can  cordially  recommend  this  work  to  all 
which  accompany  this  part  of  the  work  will  prove  of  who  wish  a  text-book  on  the  ear. — New  Orleans  Medi- 
much  use  to  the  student.    The  second  part  of  the    cal  and  Surgical  Journal,  Feb.  1885. 


JTJLER  ON  THE  EYE. 
A  Handbook  of  Ophthalmic  Science  and  Practice.    By  Henry  E. 

Juler,  F.R.C.S.,  Senior  Assistant  Surgeon,  Royal  Westminster  Ophthalmic  Hospital ;  late 
Clinical  Assistant,  Moorfields,  London.  In  one  handsome  octavo  volume  of  460  pages,  with  125 
woodcuts,  27  colored  plates,  selections  from  the  Test-types  of  Jaeger  and  Snellen,  and  Holm- 
gren's Color-blindness  Test.    Cloth,  $4.50  j  leather,  $5.50. 

The  book  cannot  fail  to  be  a  success.  In  it  a  suf-  j  on  the  more  practical  points.  The  author's  descrip- 
ficiently  exhaustive,  well-written,  and  generally  accu-  j  tions  of  the  various  operations,  illustrated  as  they  are 
rate  description  is  given  of  all  the  diseases  of  the  eye  by  excellent  woodcuts,  leave  little  to  be  desired,  and 
likely  to  be  met  with.  Only  the  points  necessary  for  the  numerous  plates  interspersed  through  the  text 
a  thorough  understanding  of  the  subject  are  intro-  cannot  fail  to  make  the  book  a  most  useful  one  for 
duced.  Throughout  the  work  a  careful  selection  has  students  of  ophthalmology.— Edinburgh  Medical  Jour- 
been  made  of  those  scientific  facts,  whether  ana-  waZ,  October,  1884. 
tomical,  physiological,  or  optical,  which  directly  bear 


J&itrFull  descriptive  Catalogue  will  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


The  American  Journal  of  the  Medical  Sciences. 


A  quarterly  containing  over  300  octavo  pages  in  each  issue.  Published  simultane- 
ously in  Philadelphia  and  London  on  the  first  days  of  January,  April,  July 
and  October.  Price,  $5.00  per  annum,  post-paid. 

{The  International  Journal  of  the  Medical  Sciences.) 


WITH  the  year  1886  The  American  Journal  of  the  Medical  Sciences  became 
in  Great  Britain  the  recognized  organ  of  the  profession — a  position  similar  to  that 
occupied  by  it  in  America  for  sixty-six  years.  The  enlargement  of  its  field  of  usefulness 
was  welcomed  abroad  with  acclamation,  and  one  hundred  and  thirty-five  of  the  fore- 
most English  practitioners  shortly  authorized  the  use  of  their  names  as  contributors  in 
order  to  aid  in  extending  over  their  country  the  benefits  which  American  medicine  has 
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ability  this  country  can  well  afford  to  entrust  her  reputation. 

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guished above  all  others  by  the  practical  character  of  their  labors,  The  Journal 
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In  the  Quarterly  Summary  of  Progress  each  separate  branch  of  medical  science 
has  been  assigned  to  a  thoroughly  competent  specialist,  who  furnishes  a  well-digested 
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speaking  nations,  and  laying  before  them  a  periodical  destined  to  mark  a  new  era  in 
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A  National  "Weekly  Periodical,  containing  Twenty-eight  to  Thirty-two  Quarto 
Pages  in  each  Issue.  Price,  $5.00  per  Annum,  in  Advance. 


Possessing  a  most  efficient  organization,  The  News  unites  the  best  features  of  the 
medical  magazine  and  newspaper.  Its  large  and  able  editorial  staff  discusses  in  each 
issue  the  important  topics  of  the  day  in  a  thoughtful  and  scholarly  manner,  and  its 
corps  of  qualified  reporters  and  correspondents,  covering  every  medical  centre,  insures 
that  its  readers  shall  be  promptly  and  thoroughly  posted  upon  all  matters  of  interest  in 
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the  form  of  Clinical  Lectures  and  Hospital  Notes,  and  in  the  pages  devoted  to  the 
Progress  of  Medical  Science  are  found  early  notes  of  all  important  advances,  gleaned 
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will  be  the  appearance  at  frequent  intervals  of  a  special  series  of  practical  articles, 
showing  the  methods  of  treating  various  prevalent  diseases  adopted  in  the  principal 
hospitals  of  the  country.  These  concise  and  authoritative  notes  on  practice  must 
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THE 


AMERICAN  JOURNAL 

OF  THE 

MEDICAL  SCIENCES. 

(the  international  journal  of  the  medical  sciences.) 
edited  by 

I.  MINIS  HAYS,  A.M.,  M.D., 

PHILADELPHIA, 

AND 

MALCOLM  MORRIS,  M.R.C.S., 

LONDON. 

NEW  SERIES. 
VOLUME  XCIV. 


P H ILADELPHIA: 

LEA  BEOTIIEKS  &  CO. 
1887. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1887,  by 

LEA  BROTHEES  &  CO., 
In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


Philadelphia: 
dor  nan,  printer, 
N.  W.  ccr.  Seventh  and  Arch  Streets. 


TO  READERS  AND  CORRESPONDENTS. 


All  communications  intended  for  insertion  in  the  Original  Department  of  this  Journal  are  only 
received  with  the  distinct  understanding  that  they  are  sent  for  publication  to  this  Journal  alone. 
Gentlemen  favoring  us  with  their  communications  are  considered  to  be  bound  in  honor  to  a  strict 
observance  of  this  understanding. 

Contributors  who  wish  their  articles  to  appear  in  the  next  number  are  requested  to  forward  them 
before  the  10th  of  July  to  the  Editor, 

No.  1004  "Walnut  Street,  Philadelphia,  TJ.  S.  A.  ;  or 

No.  63  Montagu  Square,  Hyde  Park,  "W.  London,  England. 

Liberal  compensation  is  made  for  articles  used.    Extra  copies,  in  pamphlet  form  with  cover,  will 
be  furnished  to  authors  in  lieu  of  compensation,  provided  the  request  for  them  be  written  on  the  manuscript. 
The  following  works  have  been  received  for  review  : 

Medical  Electricity  :  A  Practical  Treatise  on  the  Applications  of  Electricity  to  Medicine  and  Surgery. 
By  Roberts  Bartholow,  A.M.,  M.D.,  LL.D.,  Professor  of  Materia  Medica,  General  Therapeutics,  and 
Hygiene,  in  the  Jefferson  Medical  College  of  Philadelphia,  etc.  Third  edition,  enlarged  and  improved. 
Philadelphia  :  Lea  Brothers  &  Co.,  1887. 

The  Practitioner's  Handbook  of  Treatment;  or,  the  Principles  of  Therapeutics.  By  J.  Milner 
Fothergill,  M.D.,  Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest,  Victoria  Park, 
etc.    Third  edition.    Philadelphia  :  Lea  Brothers  &  Co.,  1887. 

The  Year-Book  of  Treatment  for  1886.    Philadelphia  :  Lea  Brothers  &  Co.,  1886. 

The  Nursing  and  Care  of  the  Nervous  and  the  Insane.  By  Charles  K.  Mills,  M.D.,  Professor  of 
Diseases  of  the  Mind  and  Nervous  System  in  the  Philadelphia  Polyclinic.  Philadelphia  :  J.  B.  Lippin- 
cott  Co.,  1887. 

Maternity,  Infancy,  Childhood.  Hygiene  of  Pregnancy ;  Nursing  and  Training  of  Infants  ;  The 
Care  of  Children  in  Health  and  Disease.  By  John  M.  Keating,  M.D.,  Visiting  Obstetrician,  and  Lecturer 
on  the  Diseases  of  Women  and  Children,  Philadelphia  Hospital.  Philadelphia:  J.  B.  Lippincott  Co., 
1887. 

Sphygmography  and  Cardiography.  Physiological  and  Clinical.  By  Alonzo  T.  Keyt,  M.D.  Edited 
by  Asa  B.  Isham,  M.D.,  and  M.  H.  Keyt,  M.D.    New  York  :  G.  P.  Putnam's  Sons,  1887. 

The  Diseases  of  the  Ear,  and  their  Treatment.  By  Arthur  Hartman,  M.D.  Berlin.  Translated 
from  the  third  German  edition  by  James  Erskine,  M.A.,  M.B.,  Surgeon  for  Diseases  of  the  Ear  to 
Anderson's  College  Dispensary,  Glasgow,  etc.    New  York :  G.  P.  Putnam's  Sons,  1887. 

Anatomy,  Descriptive  and  Topographical,  in  625  illustrations.  By  Carl  Heitzmann,  M.D.  English 
edition,  by  Louts  Heitzmann,  M.D.    New  York  :  J.  H.  Vail  &  Co.,  1887. 

Agriculture  in  some  of  its  Relations  with  Chemistry.  By  F.  H.  Storer,  S.B.,  A.M.,  Professor  of 
Agricultural  Chemistry  in  Harvard  University.  In  two  volumes.  New  York  :  Charles  Scribner's 
Sons,  1887. 

Dermatitis  Venenata  :  An  Account  of  the  Action  of  External  Irritants  upon  the  Skin.  By  James  C. 
"White,  M.D.,  Professor  of  Dermatology,  Harvard  University    Boston  :  Cupples  &  Hurd,  1887. 

Dr.  F.  Beilsteiu's  Lessons  in  Qualitative  Chemical  Analysis,  Arranged  on  the  Basis  of  the  Fifth  Ger- 
man edition.  "With  copious  additions,  including  chapters  on  Chemical  Manipulations,  Analysis  of  Or- 
ganic Substances,  and  Lessons  in  Volumetric  Analysis.  By  Chart.es  0.  Curtman,  M.D.,  Professor  of 
Chemistry  in  the  Missouri  Medical  College,  and  in  St.  Louis  College  of  Pharmacy.  Second  edition. 
St.  Louis,  Mo.,  1886. 

Physiological  Laboratory.    Harvard  Medical  School,  Boston.    Collected  Papers,  1880-1886. 

Public  Health.  The  Lomb  Prize  Essays  award  made  at  the  Thirteenth  Annual  Meeting  of  the 
American  Public  Health  Association,  Washington,  D.  C,  December  10,  1885.  With  an  Appendix. 
Second  edition.    Concord,  N.  H.,  1886. 

American  Public  Health  Association,  Lomb  Prize  Essays.  Healthy  Homes  and  Foods  for  the  Work- 
ing Classes.  By  Victor  C.  Vaughan,  M.D.,  Ph.D.,  Professor  in  University  of  Michigan.  Concord, 
N.  H.,  1886. 

Elementary  Microscopical  Technology.  A  Manual  for  Students  of  Microscopy.  In  three  parts.  Part 
I.  The  Technical  History  of  a  Slide  from  the  Crude  Materials  to  the  Finished  Mount.  By  Frank  L. 
James,  Ph.D.,  M.D.,  President  of  St.  Louis  Society  of  Microscopists.    St.  Louis,  1887. 


4 


TO  READERS  AND  CORRESPONDENTS. 


Dose  and  Price  Labels  of  all  the  Drugs  and  Preparations  of  the  Pharmacopoeia  of  1880.  Together 
with  Many  Unofncinal  Articles  that  are  frequently  called  for  as  Medicines  or  used  in  the  Arts.  For 
the  use  of  Pharmacists,  Physicians,  and  Students.  Second  edition.  By  C.  L.  Lochman.  Philadelphia, 
1887. 

Earth  as  a  Topical  Application  in  Surgery.  By  Addinell  Hewson,  M.D.  Second  edition.  Phila- 
delphia :  The  Medical  Register,  1887. 

The  Hygiene  of  the  Vocal  Organs.  A  Practical  Handbook  for  Singers  and  Speakers.  By  Moeell 
Mackenzie,  M.D.  Lond.,  Consulting  Physician  to  the  Hospital  for  Diseases  of  the  Throat.  Third  edi- 
tion.   London  :  Macmillan  &  Co.,  1887. 

A  Text-book  of  Pathological  Anatomy  and  Pathogenesis.  By  Ernst  Ziegler,  Professor  of  Patho- 
logical Anatomy  in  University  of  Tubingen.  Translated  and  Edited  for  English  students  by  Donald 
MacAlister,  M.D.,  F.R.C.P.    Part  II.    London  and  New  York  :  Macmillan  &  Co.,  188C. 

On  the  Causation  of  Club-foot.  By  Robert  William  Parker,  Surgeon  to  the  East  London  Children's 
Hospital,  etc.    London,  1887. 

Litholapaxy  in  Male  Children  and  Male  Adults.  By  Surgeon-Major  D.  F.  Keegan,  M.D.  Dub., 
Bengal  Medical  Service,  Residency  Surgeon,  Indore,  Central  India.    Loudon,  1887. 

Hip  Disease  in  Childhood.  With  special  reference  to  its  Treatment  by  Excision.  By  G.  A.  Wright, 
B.A.,  M.B.  Oxon.,  F.R.C.S.  Eng.,  Assistant  Surgeon  to  the  Manchester  Royal  Infirmary.  London  : 
Longmans,  Green  &  Co.,  1887. 

Congenital  Club-foot ;  its  Nature  and  Treatment,  with  especial  reference  to  the  Subcutaneous  Division 
of  the  Tarsal  Ligaments.  By  Robert  William  Parker,  Surgeon  to  the  East  London  Hospital  for 
Children,  and  to  Grosvenor  Hospital  for  Women  and  Children.    London  :  H.  K.  Lewis,  1887. 

The  Royal  London  Ophthalmic  Hospital  Reports.  Edited  by  R.  Marcus  Gunn,  M.D.,  F.R.C.S. 
Vol.  XI.    Part  III.    January,  1887.  London. 

The  Middlesex  Hospital  Reports  of  the  Medical,  Surgical,  and  Pathological  Registrars  for  the  year 

1885.  London :  H.  K.  Lewis,  1887. 

Transactions  of  the  Obstetrical  Society  of  London.  Vol.  XXVIII.  for  the  year  1886.  Part  IV.  for 
October,  November,  and  December.    London,  1887. 

Hygiene  des  Maternites,  Resultats  de  huit  armees  d' Observations  a  la  Maternite  de  Pellegrin  (Bor- 
deaux).   Par  Dr.  Ore,  Professeur  a  la  Faculte  de  Medecine,  etc.    Paris  :  J.  B.  Bailliere  et  Fils,  1887. 

Hysteries  et  Traumatisms  Paralysies  Contractures  Arthralgies  Hystero  Traumatiques.  Par  le  Dr. 
Paul  Berbez.    Paris  :  A  Delahaye  et  Lecrosnier,  1887. 

L' Amputation  du  Membre  superieur  dans  la  Contiguite  du  Tronc  (Amputation  Interscapulo-Thora- 
cique).    Par  Paul  Berger,  Chirurgien  de  1'  Hopital  Tenon.    Paris  :  G.  Masson,  1887. 

M.  Pasteur  et  La  Rage.  Par  Dr.  Lutaud,  Redacteur  en  Chef  du  Journal  de  Medecine  de  Paris. 
Paris  :  J;  Levy,  1887. 

De  l'Endometrite  et  de  son  Traitement.    Par  J.  A.  Doleris.    Paris,  1887. 

Hemorrhagies  Uterines,  par  le  Docteur  Sneguireff ;  edition  Francaise  ;  redigee  par  M.  H.  Varnier, 
Interne  des  Hopitaux  de  Paris,  sous  la  direction  de  M.  le  Docteur  Pinard,  Professeur  Agrege  a  la 
Faculte  de  Paris.    Paris  :  G.  Steinheil,  1886. 

Handbuch  der  allgemeinen  und  speciellen  Arzneiverordnungslehre.  Auf  Grundlage  der  neuesten 
Pharmacopceen  bearbeitet.  Von  Dr.  C.  A.  Ewald,  Professor  an  der  kgl.  Universitat  in  Berlin.  Elfte 
neu  umgearbeitete  und  vermehrte  Auflage.    Berlin  :  August  Hirschvvald,  1887. 

Die  Gesundheitspfiege  in  der  Mittelschule.  Von  Dr.  Leo  Burgerstein  in  Wien.  Wien  :  Alfred 
Holder,  1887. 

The  Influence  of  Maternal  Impressions  on  the  Foetus.  By  Fordyce  Barker,  M.D.,  LL.D.  New  York, 
1887. 

Annual  Address  delivered  before  the  American  Academy  of  Medicine  at  Pittsburg,  Pa.,  October  12, 

1886.  By  R.  S.  Sutton,  A.M.,  M.D. 

Persistent  Pain  after  Abdominal  Section.    By  James  B.  Hunter,  M.D.    New  York,  1887. 

Operations  for  Phimosis  as  a  Means  of  Cure.  Relief  of  some  Nervous  and  other  Symptoms.  By  G. 
L.  Magruder,  M.D.    Chicago,  1887. 

The  Uses  of  Massage  in  Medical  Practice.  Tracts  on  Massage  translated  from  the  German  of  Reib- 
mayr,  with  Notes.    By  Benjamin  Lee,  A.M.,  M.D.,  Ph.D.    Philadelphia,  1887. 

Forensic  Surgery.  Wm.  Zuppan  vs.  Wm.  Dickinson,  M.D.  Verdict  for  Defendant.  John  D.  Johnston, 
Esq.,  Counsel. 

A  Novel  System  of  Operating  for  the  Correction  of  the  Deflected  Septum  by  means  of  an  Electric 
Motor  Nasal  Drill  and  an  original  Spray-producing  device.  With  illustrative  cases.  By  Wm.  Chap- 
man Jarvis,  M.D.    New  York,  1887. 

Evacuant  Medication.    Cathartics  and  Emetics.    By  Henry  M.  Field,  M.D.    Philadelphia,  1887. 

Malarial  Hemorrhage.  Written  by  request  of  the  Medical  Society  of  Virginia.  By  Otis  Frederick 
Manson,  M.D.,  of  Richmond,  Va. 

Some  Observations  upon  the  Modern  Treatment  of  Urethritis.  (Read  by  invitation  before  the  New  York 


TO   READEKS  AND  COREESPONDENTS. 


5 


Dermatological  Society.)  By  George  E.  Brewer,  M.D.,  Assistant  Surgeon  to  the  Outdoor  Department 
of  Roosevelt  Hospital.    New  York.  1887. 

Researches  into  the  Etiology  of  Dengue.  By  J.  W.  McLaughlin,  M.D.,  of  Austin,  Texas.  Chicage, 
1886. 

Periostitis.  By  N.  Senn,  M.D.,  Professor  of  the  Principles  and  Practice  of  Surgery  and  Clinical 
Surgery.    Milwaukee,  1886. 

The  Antiseptic  Treatment  of  Summer  Diarrhoea.  By  L.  Emmett  Holt,  A.M.,  M.D.,  Attending  Phy- 
sician to  the  New  York  Infant  Asylum. 

Abuse  of  Alcoholics  by  the  Healthy.    By  Stanford  C.  Chaille,  A.M.,  M.D.    Concord,  1886. 

Iliac  Phlegmons.  Some  Considerations  of  Anatomical  and  Surgical  Interest.  By  Rudolph  Matas, 
M.D.,  1886. 

The  Doctorate  Address  delivered  at  the  Semi-centennial  Anniversary  of  the  University  of  Louisville, 
Medical  Department.    By  David  W.  Yandell,  M.D.    March  2,  1887. 

Dermatological  Notes.    By  J.  Clark  M'Guire,  M.D.,  Dermatologist,  Louisville  City  Hospital. 

Address  on  the  Duties  and  Conduct  of  Nurses  in  Private  Nursing.  By  Wm.  L.  Richardson,  M.D., 
Visiting  Physician  of  the  Massachusetts  General  Hospital.    Boston,  1887. 

The  Question  of  Hemorrhage  following  Uvulotomy.  By  Etiielbert  Carroll  Morgan,  A.B  ,  M.D., 
Washington,  D.  C,  First  Vice-President  of  the  American  Laryngological  Association.  New  York, 
1886. 

A  Contribution  to  the  Study  of  the  Operation  of  Shortening  the  Round  Ligaments  :  Alexander's  Ope- 
ration.   By  Thomas  A.  Ashby,  M.D.    Baltimore,  1887. 

Report  of  the  Committee  on  Disinfectants,  presented  at  the  Eourteenth  Annual  Meeting  of  the 
American  Public  Health  Association,  held  at  Toronto,  Canada,  October  5-8,  1886.  Concord,  N.  H, 
1887. 

Report  of  the  Special  Committee  (appointed  December  11,  1885)  on  the  Disinfection  of  Rags.  Pre- 
sented at  the  Eourteenth  Annual  Meeting  of  the  American  Public  Health  Association,  Toronto,  Canada, 
October,  1886.    Concord,  N.  H.,  1887. 

Maternal  Impressions.  Discussion  on  Dr.  Barker's  Essay.  By  Samuel  C.  Busey,  M.D.  Washington, 
D.  C,  1887. 

A  New  Explanation  of  the  Renal  Troubles,  Eclampsia,  and  other  Pathological  Phenomena  of  Preg- 
nancy and  Labor.    By  A.  F.  A.  King,  M.D.    New  York,  1887. 

Thomson's  Disease.    Myotonia  Congenita.    By  Dr.  Geo.  W.  Jacobt.    New  York,  1887. 

Transplantation  of  a  Rabbit's  Eye  into  the  Human  Orbit.  By  Charles  H.  May,  M.D.  New  York, 
1887. 

Practical  Examples  in  Prescription  Writing.    By  Charles  H.  May,  M.D.    New  York,  1887. 
Congenital  Haemophilia,  with  the  History  of  a  Remarkable  Case.    By  Edward  C.  Wendt,  M.D., 
February  19,  1887. 

Some  Considerations  concerning  Cancer  of  the  Uterus,  especially  its  Palliative  Treatment  in  its  later 
stages.    By  Andrew  F.  Currier,  M.D.    New  York,  1887. 

Uterine  Fibroids  and  other  Pelvic  Tumors  ;  their  Therapeutic  Treatment  and  Conduct  to  the  Meno- 
pause.   By  Henry  Frazer  Campbell,  M.D.  1887. 

The  Curability  of  Epilepsy  and  Epileptoid  Affections  by  Galvanism  and  the  Phosphated  and  Arsenided 
Bromides.   January,  1887. 

New  Treatment  of  the  Affections  of  the  . Respiratory  Organs  and  of  Blood  Poison  by  Rectal  Injections 
of  Gases,  after  the  Method  of  Dr.  Bergeon.  By  Dr.  V.  Morel.  Translated  from  the  French  by  L.  E. 
Holman.    Philadelphia  :  James  W.  Queen  &  Co. 

Removal  of  the  Uterine  Appendages.  Nine  Consecutive  Cases.  By  Mary  A,  Dixon  Jones,  M.D. 
New  York,  1886. 

Infants.  Their  Chronological  Progress.  By  Prof.  Stanford  E.  Chaill£,  M.D.,  Tulane  University 
of  Louisiana. 

Granular  Conjunctivitis  with  and  without  Pannus.    By  W.  Cheatham,  M.D. 

Proceedings  and  Addresses  at  a  Sanitary  Convention  held  at  Big  Rapids,  Michigan,  November  18  and 
19,  1886,  under  the  direction  of  a  Committee  of  the  State  Board  of  Health  and  a  Committee  of  Citizens 
of  Big  Rapids.    Two  books. 

Report  upon  the  Births,  Marriages,  and  Deaths  in  the  State  of  Rhode  Island  for  the  Year  1SS5.  Pre- 
pared by  Charles  H.  Fisher,  M.D  ,  State  Registrar  of  Vital  Statistics.    Providence,  1S86. 

The  Biennial  Report  of  the  State  Board  of  Health  of  the  State  of  West  Virginia,  for  the  years  1885 
and  1886.    Charleston,  1886. 

The  Report  of  the  State  Board  of  Health  of  Minnesota,  1884-1886,  with  Appendix  containing  Special 
Reports.    Red  Wing,  1887. 

Report  of  the  Board  of  Health  for  the  City  of  Reading  for  the  year  1886. 

Report  of  the  Commission  for  Better  Provision  of  Insane  Criminals.    New  York,  February  16,  18S6. 
Annual  Report  of  the  Medical  Superintendent  of  the  State  Asylum  for  Insane  Criminals.  Auburn, 
September,  30,  1886. 


6 


TO   READERS  AND  CORRESPONDENTS. 


Annual  Report  of  the  Trustees  of  the  Massachusetts  General  Hospital  and  McLean  Asylum,  1886. 
Printed  at  the  expense  of  the  Bowditch  History  Fund.    Boston,  1887. 

Annual  Report  of  the  Cincinnati  Hospital  to  the  Mayor  of  Cincinnati  for  the  fiscal  year  ending 
December  30,  1886.    H.  M.  Jones,  Superintendent.    Cincinnati,  1887. 

Transactions  of  the  Pathological  Society  of  Philadelphia.  Vol.  XII.  Containing  the  Report  of  the 
Proceedings  from  September,  1883,  to  July,  1885.  Edited  by  W.  E.  Hughes,  M.D.,  Medical  Registrar 
of  the  University  Hospital.    Philadelphia,  1886. 

Transactions  of  the  Massachusetts  Medico-Legal  Society.    Vol.  I.    No.  9,  1886.    Boston,  1886. 

Proceedings  of  the  Academy  of  Natural  Sciences  of  Philadelphia.  Part  III.  October-December, 
1886.    Philadelphia,  1887. 

Transactions  of  the  Seventeenth  Annual  Session  of  the  Medical  Society  of  Virginia,  held  at  Fredricks- 
burg,  Va.,  September  26,  27,  28,  1886.    Richmond,  1886. 


The  following  Journals  have  been  received  in  exchange  : 


Albany  Medical  Annals. 

American  Journal  of  Insanity. 

American  Journal  of  Obstetrics. 

American  Journal  of  Pharmacy. 

American  Journal  of  Science. 

American  Lancet. 

American  Medical  Digest. 

American  Practitioner  and  News. 

Annals  of  Surgery. 

Archives  of  Ophthalmology. 

Archives  of  Otology. 

Atlanta  Medical  and  Surgical  Journal. 

Boston  Medical  and  Surgical  Journal. 

Buffalo  Medical  and  Surgical  Journal. 

Chicago  Medical  Journal  and  Examiner. 

Chicago  Medical  Standard. 

Cincinnati  Lancet  and  Clinic. 

Cincinnati  Medical  News. 

Cleveland  Medical  Gazette. 

College  and  Clinical  Record. 

Columbus  Medical  Journal. 

Daniels'  Medical  Journal.  . 

Dental  Cosmos. 

Denver  Medical  Times. 

Druggist's  Circular. 

Ephemeris. 

Gaillard's  Medical  Journal. 

Journal  of  the  American  Medical  Association. 

Journal  of  the  Franklin  Institute. 

Journal  of  Nervous  and  Mental  Diseases. 

Kansas  City  Medical  Record. 

Kansas  City  Medical  Index. 

Maryland  Medical  Journal. 

Medical  Age. 

Medical  Herald. 

Medical  Press  of  Western  New  York. 
Medical  and  Surgical  Reporter. 


Medical  Record. 

Mississippi  Valley  Medical  Monthly. 
Nashville  Journal  of  Medicine  and  Surgery. 
New  Orleans  Medical  and  Surgical  Journal. 
New  York  Medical  Journal. 
North  Carolina  Medical  Journal. 
Northwestern  Lancet. 
Obstetric  Gazette. 

Pacific  Medical  and  Surgical  Journal. 
Peoria  Medical  Monthly. 
Philadelphia  Medical  Times. 
Physician  and  Surgeon. 
Pittsburg  Medical  Review. 
Polyclinic. 

Popular  Science  Monthly. 
Progress. 

Quarterly  Compendium  of  Medical  Science. 
Quarterly  Journal  of  Inebriety. 
Sanitarian. 
Sanitai-y  Engineer. 
Sanitary  News. 

Southern  California  Practitioner 

Southern  Medical  Record. 

Southern  Practitioner. 

St.  Joseph  Medical  Herald. 

St.  Louis  Courier  of  Medicine. 

St.  Louis  Medical  and  Surgical  Journal. 

Texas  Courier  of  Medicine. 

Therapeutic  Gazette. 

Virginia  Medical  Monthly. 

Weekly  Medical  Review. 

Western  Medical  Reporter. 

Canada  Lancet. 

Canada  Medical  Record. 

Canada  Medical  and  Surgical  Journal . 

Canadian  Practitioner. 

L' Union  Medical  de  Canada. 


The  usual  list  of  European  exchanges  have  been  received,  but  their  individual  acknowledgment  is 
omitted  from  lack  of  space. 


CONTENTS. 


ORIGINAL  COMMUNICATIONS. 

PAGE 

Sarcoma  of  the  Female  Breast ;  Based  upon  a  Study  of  One  Hundred  and 
Fifty-six  Cases.  By  Samuel  W.  Gross,  M.D.,  LL.D.,  Professor  of  the 
Principles  of  Surgery  and  Clinical  Surgery  in  the  Jefferson  Medical 
College  of  Philadelphia  17 

On  the  Remedial  Value  of  Bloodletting.  By  J.  A.  Macdougall,  M.D., 
F.R.C.S.  Ed.,  Consulting  Surgeon  to  the  Cumberland  Infirmary,  etc.  .  37 

Precocious  Gummata.  By  R.  W.  Taylor,  M.D.,  Surgeon  to  Charity 
Hospital,  New  York  53 

Bacteriology.  By  W.  Watson  Cheyne,  M.B.,  F.R.C.S.,  Assistant  Sur- 
geon to  King's  College  Hospital,  London ;  Examiner  in  Surgery  to  the 
University  of  Edinburgh,  etc.       .    ■  69 

The  Etiology  and  Mechanism  of  Asthma.  By  William  C.  Glasgow, 
M.D.,  Professor  of  Diseases  of  the  Chest  and  Throat  in  the  St.  Louis 
Post-graduate  School  of  Medicine  ;  Adjunct  Professor  of  Theory  and 
Practice  in  the  St.  Louis  Medical  College  107 


Environment  in  its  Relation  to  the  Progress  of  Bacterial  Invasion  in 
Tuberculosis.    By  E.  L.  Trudeau,  M.D.,  of  Saranac  Lake,  N.  Y.      .  118 

The  Pupil  in  its  Semeiological  Aspects.  By  William  Macewen,  Sur- 
geon to,  and  Lecturer  on  Surgery  to  Royal  Infirmary,  and  Surgeon  to 
Children's  Hospital,  Glasgow  123 

The  Thermal  Death-point  of  Pathogenic  Organisms.  By  George  M. 
Sternberg,  M.D.,  Major  and  Surgeon  U.  S.  Army      ....  146 

A  Consideration  of  the  Results  in  327  Cases  of  Tracheotomy,  Performed 
at  the  Boston  City  Hospital  from  1864  to  1887.  By  Robert  W. 
Lovett,  M.D.,  and  John  C.  Munro,  M.D.,  formerly  House  Surgeons 
at  the  Hospital  160 


8 


CONTENTS. 


REVIEWS. 


The  Science  and  Art  of  Obstetrics.  By  Theophilus  Parvin,  M.D., 
LL.D.,  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children 
in  the  Jefferson  Medical  College,  Philadelphia,  and  one  of  the  Obste- 
tricians to  the  Philadelphia  Hospital  171 

Diseases  of  the  Joints.  By  Howard  Marsh,  F.E.C.S.,  Senior  Assistant 
Surgeon  to,  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital, 
Senior  Surgeon  to  the  Hospital  for  Sick  Children,  and  to  the  Alexan- 
dria Hospital  for  Hip  Disease  183 


Recent  Works  on  the  Treatment  of  the  Insane. 

1.  The  Curability  of  Insanity :  A  Series  of  Studies.  By  Pliny  Earle, 
A.M.,  M.D.,  late  Superintendent  of  the  State  Lunatic  Hospital,  at 
Northampton,  Massachusetts,  etc. 

2.  The  Private  Treatment  of  the  Insane  as  Single  Patients.  By  Ed- 
ward East,  M.R.C.S.,  L.S.  A.,  Member  of  the  Medico-Psychological 
Association. 

3.  Insanity  and  Allied  Neuroses :  Practical  and  Clinical.  By  George 
H.  Savage,  M.D.,  M.R.C.P.,  Physician  and  Superintendent  of 
Bethlem  Royal  Hospital,  etc.    ,  189 

Le  Langage  Interieur,  et  les  diverses  formes  de  l'Aphasie.  Par  Gilbert 
Ballet,  Professeur  agrege  a  la  Faculte  de  Medecine  de  Paris. 

Inner  Speech  and  the  Different  Forms  of  Aphasia.  By  Gilbert  Ballet, 
Associate  Professor  of  the  Faculty  of  Medicine  in  Paris       .       .  .195 

On  Aphasia;  Being  a  Contribution  to  the  Subject  of  the  Dissolution  of 
Speech  from  Cerebral  Disease.    By  James  Ross,  M.D.,  LL.D.    .       .  195 

Department  of  the  Interior.  Bulletin  of  the  United  States  Geological 
Survey,  No.  32.    Mineral  Springs  of  the  United  States  ....  197 

Transactions  of  the  American  Ophthalmological  Society.  Twenty-second 
Annual  Meeting,  1886    199 

L' Amputation  du  Membre  Superieur  dans  la  Contiguite  du  Tronc.  (Am- 
putation Interscapulo-thoracique. )  Par  Paul  Berger,  Chirurgien 
de  l'Hopital  Tenon,  Professeui  agrege  a  la  Faculte  de  Medecine, 
Membre  de  la  Societe  de  Chirurgie. 

Interscapulo -thoracic  Amputation  of  the  Upper  Extremity.    By  Prof. 


Paul  Berger       .   202 

Before  Trial.  What  should  be  done  by  Client,  Solicitor,  and  Counsel. 
By  Richard  Harris,  Barrister  at  Law.  Together  with  a  Treatise  on 
the  Defence  of  Insanity   .  203 


The  Hygiene  of  the  Vocal  Organs.    A  Practical  Handbook  for  Singers 
and  Speakers.    By  Morell  Mackenzie,  M.D.  Lond  205 


CONTENTS. 


9 


PAGE 

Diseases  of  the  Ear,  and  their  Treatment.  By  Arthur  Hartmann, 
M.D.  (Berlin) ;  translated  from  the  third  German  edition  by  James 
Erskine,  M.B  206 

Handbuch  der  Allgemeinen  und  Speciellen  Arzneiverordnungslehre. 
Auf  Grundlage  der  neuesten  Pharmacopoeen.  Bearbeitet  von  Dr.  C.  A. 

EWALD. 

Handbook  of  General  and  Special  Therapeutics.    By  Dr.  C.  A.  Ewald  207 

Hip  Disease  in  Childhood,  with  Special  Beference  to  its  Treatment  by 
Excision.  By  G.  A.  Wright,  B.A.,  M.B.  Oxon.,  F.B.C.S.  Eng.,  As- 
sistant Surgeon  to  the  Manchester  Boyal  Infirmary;  Lecturer  in  Clin- 
ical Surgery  in  the  Owens  College,  etc  208 

Analysis  of  the  Urine,  with  Special  Beference  to  the  Diseases  of  the 
Genito-Urinary  Organs.  By  B.  B.  Hofmann,  Professor  in  the  Uni- 
versity of  Gratz,  and  B.  Ultzmaxk,  Docent  in  the  University  of 
Vienna.  Translated  by  T.  Bartox  Brune,  A.M.,  M.D.,  etc.,  and  H. 
Holbrook  Curtis,  Ph.B.,  M.D.,  etc.  .  209 

Die  Ursachlichen  Momenten  der  Augenmuskellahmungen :  die  nicht- 
nuclear  Lahmungen.  Von  L.  Mauthker,  K.  K.  Universitats  Prof,  in 
Wien. 

The  Causal  Conditions  of  Muscular  Paralysis  of  the  Eye :  Non-Nuclear 
Paralysis.    By  Prof.  L.  Mauthker    .       .       .       .       .       .       .  210 


QUARTERLY  SUMMARY 

OF  THE 

PEOGEESS  OF  MEDICAL  SCIENCE. 


ANATOMY. 
Under  the  charge  of  George  D.  Thaxe,  M.R.C.S.  Exg., 

Professor  of  Anatomy  at  University  College,  London. 


The  Constitution  of  the  Bestiform  Body.  By  W.  Bechterew  .  .  .211 
The  Morphology  of  the  Sacral  Plexus.    By  A.  M.  Paterson     .       .  .212 

On  the  Bursa  Pharyngea.    By  F.  J.  C.  Mayer  212 

On  the  Closure  of  the  Cardiac  Orifice  of  the  Stomach.  By  A.  v.  Gubaroff  213 
On  the  Position  of  the  Duodenum,  of  the  Ileocolic  Junction,  and  of  the 

Sigmoid  Flexure.    By  P.  SchiefFerdecker  214 

On  the  Belative  Length  of  the  Fingers  and  Toes.    By  W.  Braun    .       .  215 


10 


CONTENTS. 


PHYSIOLOGY. 

Under  the  charge  of  Gerald  F.  Yeo,  M.D., 

Professor  of  Physiology  at  King's  College,  London. 


PAGE 

Visual  Centres  of  the  Cerebral  Cortex.   By  Prof.  Sigm.  Exner  and  Dr. 

Joseph  Paneth  216 

Irritability  of  the  Various  Layers  of  the  Cerebral  Cortex.    By  Drs.  Ernst 

Asch  and  Alfred  Neisser  216 

Intracardiac  Pressure.    By  J.  Magini  216 

The  Union  of  Carbonic  Acid  with  Haemoglobin.  By  Christian  Bohr  .  217 
The  Coagulation  of  the  Blood.    By  L.  C.  Wooldridge     .       .       .  .217 


MATERIA  MEDIC  A,  THERAPEUTICS,  AND 
PHARMACOLOGY. 

Under  the  charge  of  Roberts  Bartholow,  M.D.,  LL.D., 

Professor  of  Materia  Medica,  General  Therapeutics,  and  Hygiene  in  the  Jefferson  Medical  College,  Philadelphia. 


Acetanilid  (Antifebrin).    By  Weill,  Grunneberg,  Dujardin-Beaumetz,  and 

Dr.  H.  Eisenhart     ....   218 

Antiseptic  Hypodermatic  Injections.    By  Dr.  Ley   .       .       .       .       .  219 
Effects  of  Iodide  of  Potassium  on  the  Assimilation  of  Nitrogenous  Mate- 
rials.   By  Samoilow  221 

Effects  of  Alcohol  on  the  Digestive  Functions  in  the  Normal  and  in  the 

Pathological  States.    By  Dr.  A.  Gluzinski  221 

Pilocarpine  in  Catarrh  of  the  Tympanum.  By  Rosengarten  .  .  .  221 
The  Hypodermatic  Injection  of  the  Insoluble  Salts  of  Mercury.    By  Dr. 

Guelpa   .       .       .       .       .  ,  222 

The  Preventive  Treatment  of  Syphilis.  By  Prof.  Neumann  .  .  .  222 
Treatment  of  Neuralgia  of  the  Fifth  Nerve.    By  Prof.  Gussenbauer       .  223 

Cocaine  in  Cardiac  Asthenia.    By  Noorden  223 

The  Formiates  and  their  Disposal  in  the  Organism.  By  MM.  Grehaut  and 

Quinquad       ...       .       .       .  223 

Hot  Water  in  Acute  Prostatitis.    By  Dr.  Cazeaux   .       .  ■  .       .  223 

Massage  in  Sciatica.    By  Prof.  Max  Miiller  223 

Sparteine.    By  Dr.  Stoessel  .       .  224 

Salol.    By  Dr.  Fr.  Eduard  Georgi    .   224 

Iodol  and  Iodoform.    By  Schnirer  225 

Chlorhydrate  of  Pereirine.    By  Dr.  Ferreira   .       .       .  .       .  225 


CONTENTS. 


11 


MEDICINE. 
Under  the  charge  of  William  Osler,  M.D.,  F.R.C.P.  Lond., 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania. 
ASSISTED  BY 

J.  P.  Crozer  Griffith,  M.D.,  Walter  Mendelson,  M.D., 

Assistant  to  the  Professor  of  Clinical  Medicine  in  the  Instructor  in  the  Laboratory  of  the  College  of 

University  of  Pennsylvania.  Physicians  and  Surgeons,  New  YorJc. 


On  Some  Cases  of  Infectious  Cerebro-spinal  Meningitis,  with  Remarks  on 
the  Diagnosis  of  the  Disease.    By  Senator  225 


226 
227 
227 
228 


Mountain  Fever.    By  Kober,  Smart,  Hirsch,  and  Squire  . 
The  Microorganisms  in  the  Varicella  Vesicle.    By  Guttmann 

Peripheral  Neuritis.    By  Ross  

On  Pseudo-tabes  from  Arsenical  Poisoning.    By  Dana  . 
On  the  Early  Recognition  of  General  Paralysis  of  the  Insane ;  and  the 
Relation  between  this  Disease,  Tabes  Dorsalis,  and  Disseminated  Scle- 
rosis.   By  J.  Syer  Bristowe  228 

•Sudden  Death  in  Pleurisy.    By  Weill  229 

On  Cases  of  Valvular  Disease  of  the  Heart,  Existing  for  over  Five  Years 

without  Serious  Symptoms.  By  Sir  Andrew  Clark  .  .  .  .  229 
On  the  General  Pathology  of  Heart  Diseases.  By  Schott  .  .  .  230 
New  Investigations  of  the  Gallop  Rhythm.    By  Cuffer  and  Barbillion    .  232 

.Morphine  in  Diabetes.    By  T.  Mitchell  Bruce  233 

The  Occurrence  of  Albuminuria  in  Diabetes.  By  Pollatschek  .  .  233 
On  the  "Starch-concerting"  Ferment  in  Human  Urine.  By  Breusing  .  233 
On  the  Correlation  of  the  Secreta  and  Excreta  of  the  Organism.  By 

Sticker  and  Hiibner  234 

On  Digestive  Ferments  in  Normal  and  Pathological  Urines.  By  Breusing, 

Mya,  and  Belfanti  235 

Reducing  Substances,  other  than  Glucose,  in  Diabetic  Urine.  By  Leo  .  236 
;Serum-albumin  in  Normal  Urine.    By  Posner  ...       ...  236 


SURGERY. 

(IN  EUROPE.) 

Under  the  charge  of  Frederick  Treves,  F.R.C.S., 

Surgeon  to,  and  Lecturer  on  Anatomy  at,  the  London  Hospital. 


Recent  Surgical  Literature  236 

Bacteria  and  Tubercular  Abscess.    By  Dr.  Farre  239 

'The  Use  of  Iodol.    By  Dr.  F.  J.  Pick  240 


12  CONTENTS. 

PAGE 

A  New  Micrococcus.    By  Professor  Manfredi  240 

The  Incubation  Stage  of  Hydrophobia.    By  Dr.  Bauer    ....  240 

The  Treatment  of  Erysipelas.    By  Dr.  Nussbaum  241 

Cancer  of  the  Breast.    By  Mr.  H.  T.  Butlin  241 

Excision  of  the  Knee.  By  Mr.  Morrant  Baker  and  Mr.  Howard  Marsh  .  242 
Internal  Derangements  of  the  Knee-joint.  By  Professor  Annandale  .  242 
Amputation  in  Diabetic  Gangrene.  By  Professor  Konig  .  .  .  243 
E eduction  of  Shoulder  Dislocations.  By  Dr.  Macleod  ....  243 
Subluxation  of  the  Lower  Jaw  treated  by  Operation.    By  Professor 

Annandale  243 

The  Surgical  Treatment  of  Pulmonary  Cavities.    By  Mr.  Rickman  Godlee  244 

Contusion-pneumonia.    By  Dr.  A.  Koch  245 

The  Surgical  Treatment  of  Empyema.  By  Dr.  Kasanli  ....  245 
The  Surgical  Treatment  of  Affections  of  the  Pleura  and  Lungs.    By  Drs. 

Rochelt  and  Ribbing  246 

The  Diagnosis  of  Stricture  of  the  CEsophagus.    By  Professor  Ogston      .  246 

Lipoma  of  the  Mesentery.    By  M.  Terillon  246 

The  Etiology  of  Peritonitis.    By  Dr.  Grawitz  247 

The  Treatment  of  Hemorrhoids  by  Excision.  By  Mr.  Whitehead  .  .  247 
Hernia  of  the  Caecum.  By  Mr.  Frederick  Treves  and  Mr.  G.  A.  Wright  248 
Parotitis  in  Association  with  Abdominal  Disease.    By  Mr.  Stephen  Paget  248 

The  Treatment  of  Ectopion  Vesicas.    By  Dr.  Zesas  249 

Suprapubic  Lithotomy.    By  Sir  William  MacCormac    ....  249 

Lithotomy.    By  Dr.  Rosenthal  .       .  250 

Primary  Sarcoma  of  the  Bladder.    By  Dr.  Chiari  250 

The  Function  of  the  Prostate.    By  Dr.  Fiirbringer  250 

Renal  Surgery.    By  Dr.  T.  F.  Chavasse  251 

Recent  Notable  Papers  251 


(IN  AMERICA.) 


Removal  of  a  Large  Sarcoma,  causing  Hemianopsia,  from  the  Occipital 
Lobe.    By  Drs.  W.  R.  Birdsall  and  Robert  F.  Weir     .       .       .  .252 

Pleurotomy  by  Resection  of  the  Ribs  for  Empyema.  By  Dr.  W.  H. 
Strickler  253 

Pistolshot  Wound  of  the  Abdomen ;  Laparotomy ;  Nephrectomy ;  Au- 
topsy.   By  Dr.  W.  W.  Keen  254 

Splenectomy  for  Wandering  Spleen.    By  Dr.  W.  H.  Myers     .       .       .  254 

Aneurisms  Treated  by  the  Introduction  of  Catgut  or  of  Wire,  with  Elec- 
tricity.   By  Dr.  Robert  Abbe  255 

A  Case  of  Innominate  Aneurism  treated  by  Simultaneous  Distal  Liga- 
tion of  the  Right  Carotid  and  Subclavian  Arteries.  Recovery.  By  Dr. 
H.  R.  Wharton      .       .  255 

Three  Cases  of  Ligature  of  the  External  Carotid  Artery,  in  two  of  which 
both  Vessels  were  tied  Simultaneously.    By  Dr.  Jos.  D.  Bryant  .       .  256 

The  Treatment  of  Old  Dislocations  of  the  Elbow.    By  Dr.  L.  A.  Stimson  256 


CONTENTS. 


13 


OPHTHALMOLOGY. 
Under  the  charge  of  L.  Webster  Fox,  M.D., 

Ophthalmic  Surgeon  to  the  Germantown  Hospital,  Philadelphia. 


PAGE 

Ophthalmoplegia  Externa  Acuta.  By  Drs.  Berry  and  Bramwell  .  .  257 
Imperfect  Convergence  in  Exophthalmic  Goitre.    By  P.  J.  Mobius       .  258 

Syphilitic  Arteritis  of  a  Retinal  Artery.    By  Haab  258 

Physiological  Action  of  Atropia  on  the  Iris.    By  Dr.  H.  Holtzke   .       .  259 

Snow-blindness.    By  Dr.  L.  B.  Graddy  .259 

Myopia  in  the  Schools  of  Stockholm.  By  Professor  Johan  Mdmark  .  260 
Silver  Balls  as  Substitutes  for  the  Vitreous  after  Evisceration.    By  Mr. 

W.  P.  Keall  260 

Gouty  Affections  of  the  Eye.    By  M.  Zychan  260 

Transplantation  of  Rabbit's  Eye  into  the  Human  Orbit.    By  Dr.  Charles 

H.May  260 

Artificially  Produced  Cataract.    By  Messrs.  Bouchard  and  Charrin        .  261 

A  New  Cause  of  Mydriasis.    By  Dr.  Rampoldi  261 

Cataract  Extraction  without  Iridectomy.  By  Dr.  H.  Knapp  .  .  .  261 
Irrigation  of  the  Anterior  Chamber  after  Cataract  Extraction.    By  Dr. 

Grandclement  261 

Transplantation  of  the  Cornea.    By  Prof.  Adimuk  262 

Inflammation  of  the  Lachrymal  Canal.  By  Dr.  Montanelli  .  .  .  263 
Ocular  Injuries  caused  by  the  Obstetric  Forceps.  By  Berger  .  .  .  263 
Incision  of  Swollen  Optic  Nerve  Sheath,  and  Etiology  of  "  Choked  Disk." 

By  Mr.  Brundenell  Carter      .       .       .  264 

Ophthalmia  Neonatorum.    By  Dr.  C.  Bell  Taylor    .       .       .       .  .264 


OTOLOGY. 
Under  the  charge  of  Charles  H.  Btjrxett,  M.D., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medicine,  etc. 


Sarcoma  of  the  Concha.    By  Dr.  M.  D.  Jones  265 

On  the  Management  of  Perforations  of  the  Membrana  Tympani.    By  Sir 

Wm.  B.  Dalby   265 

Therapeutic  Effect  of  Iodol  in  Suppuration  of  the  Ear.    By  Dr.  Stetler  266 
Tinnitus  Aurium,  and  its  Treatment  by  a  New  Method  of  Alternate  In- 
jection and  Evacuation  of  Air.    By  Dr.  John  Ward  Cousins        .       .  266 
Abscess  in  the  Brain  resulting  from  Disease  of  the  Ear.    By  Dr.  Thomas 

Barr  267 

A  Case  of  Abscess  of  the  Temporo-sphenoidal  Lobe  of  the  Brain,  due  to 
Otitis  Media,  successfully  Treated  by  Trephining  and  Drainage.  By 
Dr.  W.  R,  Gowers  and  Mr.  Arthur  E.  Baker,  F.R.C.S.        .       .       .  268 


14 


CONTENTS. 


On  the  Surgical  Treatment  of  Brain  Suppuration  following  Ear  Disease. 
By  Dr.  E.  F.  Weir   .       .       .       .  .271 


DISEASES  OF  THE  LARYNX  AND  CONTIGUOUS 
STRUCTURES. 

Under  the  charge  of  J.  Solis-Cohen,  M.D., 

Professor  of  Diseases  of  the  Throat  and  Chest,  Philadelphia  Polyclinic. 


Diphtheria.    By  Reierson  272 

Intubation  of  the  Larynx.    By  Dr.  A.  Caille  272 

Early  Tracheotomy  in  Diphtheria.  By  Mr.  W.  Watson  Cheyne  .  .  273 
Lupus  of  the  Nose  and  Rhinoliths.  By  Dr.  L.  V.  Silitch  .  .  .  273 
Mucous  Polypi  in  the  Right  Antrum.  By  Dr.  Schaeffer  .  .  .  273 
Cyst  of  the  Nasal  Mucous  Membrane.  By  Schaeffer  ....  273 
Nasal  and  Nasopharyngeal  Reflex  Neuroses.  By  Dr.  P.  McBride  .  .  273 
Stricture  of  the  (Esophagus.    By  Dr.  J.  W.  Roosevelt  and  Mr.  Charter 

J.  Symonds  274 

Pulsating  Arteries  of  the  Pharynx.  By  Dr.  J.  W.  Farlow  .  .  .  274 
Laryngectomy.    By  Mr.  Lennox  Browne,  Drs.  D.  Hayes  Agnew,  J.  H. 

Branham,  and  W.  Gardiner  274 

Fibrosarcoma  of  the  Nasal  Septum.    By  MM.  Calmettes  and  Chatellier  .  274 

Black  Tongue.    By  Dr.  Ph.  Shech  274 

Pharyngitis  Sicca.    By  Dr.  E.  J.  Moure  275 

Laryngeal  Measurements.    By  Dr.  Moura  275 

Atrophic  Rhinitis.    By  Dr.  Noquet  275 


DERMATOLOGY. 
Under  the  charge  of  Louis  A.  Duhrixg,  M.D., 

Professor  of  Dermatology  in  the  University  of  Pennsylvania, 
AND 

Henry  W.  Stelwagon,  M.D., 

Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases. 


lchthyol.    By  Elliot  and  Unna   275 

Amenorrhea,  Septicaemia,  and  Dermatitis  Multiformis.    By  Dr.  H.  F. 

Kerr       .       .       .       .       .       .       .     -.       .       .       .       .       .  277 

Impetigo  Herpetifoimis.    By  Kaposi   277 

Two  Epidemics  of  Molluscum  Contagiosum.  By  Dr.  W.  F.  Mittendorf  278 
Merck's  Concentrated  Lactic  Acid ;  Some  of-  its  Uses  in  Dermatology. 

By  Knoche   279 


CONTENTS.  15 

PAGE 

The  Cutaneous  Punch.    By  Keyes   .       .  279 

Actinomycosis  of  the  Skin.    By  Majacchi  .279 

Dermatitis  Venenata.    By  Dr.  J.  S.  Howe  279 

Chronic  Zoster.    By  Dr.  Leudet  280 


MIDWIFERY  AND  GYNECOLOGY. 
Under  the  charge  of  D.  Berry  Hart,  M.D.,  F.R.C.P.E., 

Lecturer  on  3Fidwifery  and  Diseases  of  Women,  Surgeon's  Hall,  Edinburgh,  etc. 


Complete  Inversion  of  the  Puerperal  Uterus  :  Threatened  Gangrene,  and 

Cure  by  Laparotomy.    By  Schmalfuss  281 

Defective  Sanitation  as  a  Cause  of  Puerperal  Disease.  By  Playfair  .  281 
Treatment  in  Cases  of  Abortion  where  the  Placenta  is  Retained.  By 

Budin  282 

The  Treatment  of  Umbilical  Hernia.  By  Olshausen  ....  282 
A  Case  of  Gastrotomy  for  Extrauterine  Gestation  in  which  the  Placenta 

never  came  away.    By  Dr.  Braithwaite  283 

Foetus  and  Placenta  of  Extrauterine  Gestation  removed  by  Abdominal 

Section.    By  Dr.  Herman  283 

A  Case  of  Removal  of  both  Ovaries  during  Pregnancy.   By  Mr.  Knowsley 

Thornton  283 

On  Mercurialism  in  Lying-in  Women  undergoing  Sublimate  Irrigation. 

ByDakin  284 

Castration  in  Neuroses.    By  Schroder      ...       ....  285 

A  Case  of  Cured  Peritoneal  Tuberculosis.    By  Poten      ....  286 

On  Periuterine  Hematocele.    By  Gusserow  287 

On  Cancer  of  the  Uterus.    By  Williams  288 

The  Etiology,  Pathology,  and  Classification  of  Salpingitis.    By  Sanger  .  290 
The  Pathology  of  Chronic  Inflammatory  Disease  of  the  Uterine  Appen- 
dages as  Illustrated  by  the  Preparations  of  Sixty-three  Cases  removed 
during  the  Year  1886.    By  Mr.  Lawson  Tait  291 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Under  the  charge  of  Matthew  Hay,  M.D., 

Professor  of  Medical  Jurisprudence,  University  of  Aberdeen. 


Statistics  of  Crime  in  Europe  291 

Contribution  to  the  Medico-legal  Study  of  Footprints.    By  Masson        .  292 

Diagnosis  of  Death  by  Hanging.    By  Coutagne  293 

The  Medico-legal  Significance  of  the  Biperforate  Hymen.    By  Prof. 
Demange   293 


16 


CONTENTS. 


PAGE 

Spontaneous  Closure  of  the  Eyelids  after  Death.    By  Dr.  Valude  .       .  294 

Cicatrices  of  Leech  Bites.    By  Dr.  Castro  294 

Cocainomania.    By  Erlenmeyer  295 

Analogy  between  Dual  Insanity  and  Dual  Suicide.  By  Chpolianski       .  295 
The  Presence  of  Free  Phosphoric  Acid  as  a  Proof  of  Poisoning  by  Sul- 
phuric Acid.    By  Professor  Garnier  295 

Arsenic  in  Soil.    By  Professors  Garnier  and  Schlagdenhauffen       .       .  296 
Mode  of  Action  of  Sulphuretted  Hydrogen  and  Alkaline  Sulphides.  By 
Julius  Pohl  297 


PUBLIC  HEALTH. 
Under  the  charge  of  Shieley  F.  Murphy,  M.K.C.S., 

Lecturer  on  Hygiene  and  Public  Health,  St.  Mary's  Hospital,  London. 

Vaccination  in  Eussia.    By  Dr.  Ucke  298 

Influence  of  Smallpox  Hospitals.    By  Dr.  George  Buchanan  and  Mr. 

W.  H.  Powers   .301 

On  the  Etiology  of  Foot  and  Mouth  Disease.  By  Dr.  E.  Klein,  F.B.S.  301 
Epidemic  of  Enteric  Fever  at  Pierrefonds.  By  Mons.  Brouardel  .  .  302 
Treatment  of  Sewage.    By  Mr.  Crump  and  Mr.  Dibdin  ....  303 


THE 


AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES. 

JULY,  1  887. 


SAECOMA  OF  THE  FEMALE  BREAST; 

BASED  UPON  A  STUDY  OF  ONE  HUNDRED  AND  FIFTY-SIX  CASES. 

By  Samuel  W.  Gross,  M.D.,  LL.D., 

PROFESSOR  OF  THE  PRINCIPLES  OF  SURGERY  AND  CLINICAL  SURGERY  IN 
THE  JEFFERSON  MEDICAL  COLLEGE  OF  PHILADELPHIA. 

In  my  Treatise  on  Tumors  of  the  Mammary  Gland,  published  in  1880, 
maybe  found  a  chapter  on  sarcoma,  in  which  the  general  pathology 
and  life-history  of  the  affection  are  deduced  from  an  analysis  of  sixty 
cases  confirmed  by  microscopical  examination.  This  account  remains 
up  to  the  present  time  the  most  trustworthy  description  of  this  neoplasm 
with  which  I  am  acquainted ;  and  it  constitutes  the  only  one  in  which 
an  attempt  has  been  made  upon  anything  approaching  an  extended 
scale  to  determine  the  relations  which  exist  between  its  minute  features 
and  its  clinical  characters.  Feeling  that  many  points  were  still  obscure, 
I  have,  during  the  past  seven  years,  kept  a  careful  record  of  my  own 
cases,  and  noted  those  reported  by  other  surgeons,  so  that  my  collection 
now  embraces  one  hundred  and  fifty-six  cases,1  including  nineteen  of  my 
own,  a  critical  examination  of  which  affords  the  data  for  this  paper. 

The  varieties  and  subvarieties  of  sarcoma  of  the  female  mamma  are 
the  same  as  those  met  with  in  other  organs.  The  principal  ones — the 
spindle-celled,  round-celled,  and  giant-celled — are  determined  by  the 

1  I  have  to  express  my  thanks  to  Dr.  Sands,  Dr.  Markoe,  and  Dr.  Bull,  of  New  York,  and  Mr.  Bryant, 
of  London,  for  unpublished  cases  from  their  practice,  and  to  Mr.  Henry  Morris,  of  London,  Mr.  Hum- 
phry, of  Cambridge,  Mr.  Banks,  of  Liverpool,  Mr.  Whitson,  of  Glasgow,  aud  Mr.  Page,  of  Newcastle- 
on-Tyne,  for  the  final  histories  of  their  recorded  cases. 
NO.  CLXXXVII. — JULY,  1887.  2 


18 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


prevailing  form  of  the  cells,  and  the  first  two  are  further  separated,  in 
accordance  with  the  dimensions  of  the  cells,  into  the  small-celled  and 
large-celled.  The  subvarieties  are  constituted  by  the  nature  or  arrange- 
ment of  the  intercellular  substance  ;  by  various  transformations  or  com- 
binations with  other  neoplastic  tissues;  by  the  presence  or  absence  of 
duct  or  retention  cysts ;  and  by  the  persistence  of  glandular  elements. 
Hence  the  modified  forms  of  sarcoma  are  the  fibrous,  lymphoid,  alveolar, 
myxomatous,  cartilaginous,  osteoid,  calcifying,  melanotic,  telangiectatic, 
hemorrhagic,  cystoid,  solid,  cystic,  and  adenoid. 

Of  the  varieties  of  sarcoma,  the  spindle-celled,  which  include  the 
fibrous,  constitute  68  per  cent.,  the  round-celled  27  per  cent.,  and  the 
giant-celled  5  per  cent,  of  all  cases.1  Of  the  subdivisions,  50  per  cent, 
are  cystic,  the  term  including  the  barren  and  proliferous  cysts;  50  per 
cent,  are  solid  or  noncystic;  33  per  cent,  are  adenoid,  the  glandular 
structures  persisting  principally  in  the  spindle-celled  growths  ;  12.80  per 
cent,  are  myxomatous,  the  combination  being  almost  peculiar  to  the 
spindle-celled  and  cystic  tumors ;  7.69  per  cent,  are  telangiectatic  and 
hemorrhagic ;  7  per  cent,  are  cystoid,  or  the  seat  of  softening  cysts  ;  2.56 
per  cent,  are  osteoid;  2.56  per  cent,  are  calcifying;  1.21  per  cent,  are 
cartilaginous ;  1.92  per  cent,  are  alveolar  ;  1.21  per  cent,  are  lymphoid ; 
and  1.21  per  cent,  are  melanotic  or  pigmented.  It  is  interesting  to  note 
that  in  the  ten  examples  of  calcification,  chondrifi cation,  and  ossification, 
the  tumors  were  spindle- celled  in  seven,  and  cystic  in  five.  In  the  three 
cases  of  alveolar  sarcoma  the  tumor  was  round-celled  in  two,  and  giant- 
celled  in  one ;  while  both  of  the  pigmented  growths  were  alveolar  and 
round-celled. 

Like  the  other  encapsuled  neoplasms  of  the  mamma,  circumscribed 
sarcomata  are  ovoid,  rounded,  or  spherical,  lobed  or  bossed,  and  seldom 
smooth  and  uniform,  the  surface  irregularities  being  most  marked  in  the 
cystic  variety.  As  a  rule,  they  are  unattached  to  the  gland,  but  push  it 
aside,  compress,  and  flatten  it,  or  cause  it  to  atrophy,  although  they  are, 
in  rare  instances,  united  to  it  by  a  pedicle.  Their  consistence  varies  with 
their  minute  structure  and  degenerations,  the  pure  spindle-celled  and 
giant-celled  tumors  being  firm,  like  fibromata,  while  the  round-celled  are 
soft  and  elastic.  The  spindle-celled,  however,  are  soft  in  about  one-third 
of  all  examples,  when  they  will  be  found  to  be  composed  of  small  fusi- 
form cells,  or  to  have  undergone  myxomatous  or  fatty  transformation,  or 
to  be  the  seat  of  interstitial  hemorrhage.  The  round-celled  are  hard  in 
about  one-sixth  of  all  cases,  when  they  will  usually  be  found  to  be  rich  in 

1  Of  the  nineteen  cases  that  have  come  under  my  personal  observation,  thirteen  were  spindle-celled 
and  six  round-celled.  Of  the  former,  five  were  firm,  small  adenoid  growths  ;  one  was  a  telangiectatic 
and  myxomatous,  and  one  a  myxomatous  medullary  sarcoma ;  six  were  firm  cystic,  and  in  two  of  these 
the  cysts  were  filled  with  vegetations.  Of  the  six  round-celled,  one  was  lymphoid  ;  one  was  a  myxo- 
matous cystic  medullary  growth  ;  two  were  proliferous  cystic,  and  one  of  these  was  medullary,  and  two 
were  cystoid  medullary  tumors. 


GROSS,   SARCOMA   OF   THE   FEMALE  BREAST. 


19 


fibrous  intercellular  substance.  In  one  of  the  best  illustrations  of  round- 
celled  tumors  that  I  have  ever  seen,  the  tissue  was  dense,  so  that  they 
are  by  no  means  synonymous  with  soft,  medullary,  or  encephaloid  sarco- 
mata, although  they  are  usually  much  softer  than  the  spindle-celled 
variety,  since  they  are  peculiarly  rich  in  cells  and  bloodvessels,  and 
since  their  intercellular  substance  is  usually  mucoid.  The  spindle-celled 
growths  sometimes  creak  or  cry  under  the  knife,  in  which  event  they 
come  under  the  category  of  fibrous  sarcomata,  from  the  large  admixture 
of  fibrous  tissue.  Their  consistence  varies,  moreover,  with  their  stage  of 
development.  If  they  are  solid,  it  is  entirely  or  almost  uniform  ;  while 
they  are  soft  and  elastic,  or  soft  and  fluctuating  at  some  points,  and 
especially  at  the  larger  bosses,  and  hard  at  others,  when  they  are  the  seat 
of  cysts  occupied  by  fluid,  or  solid  contents,  or  by  both.  In  about  one- 
fourth  of  the  cystic  growths,  however,  the  tumor  is  firm  throughout,  in 
consequence  of  the  cysts  being  so  deeply  seated  as  to  elude  detection  by 
manipulation. 

On  section  the  spindle-celled  tumors  are  usually  smooth,  succulent, 
and  glistening,  and  of  a  white  or  grayish-white  color,  particularly  if 
they  are  poor  in  vessels,  the  tint  being  rosaceous- white  or  rosaceous-gray 
when  their  vascular  supply  is  larger.  The  round-celled  tumors,  on  the 
other  hand,  are  rarely  pure  white,  but,  from  their  relatively  greater 
vascularity,  reddish-white,  reddish-yellow,  or  reddish-gray,  the  hue 
being  not  infrequently  comparable  to  that  of  the  foetal  brain.  When 
they  are  highly  vascular  the  rosaceous  tint  is  very  marked,  or  they  are 
pervaded  by  macroscopic  vessels  ;  or  dotted  with  minute  spots  of  ecchy- 
mosis,  or  patches,  or  streaks  of  bright  red  or  brown,  or  various  inter- 
mediate shades  of  pigmentation.  In  not  a  few  instances  the  soft  brain- 
like tissue  is  so  extensively  interspersed  with  clots  of  blood,  and  with 
tomentous  cysts  containing  blood,  that  the  term  hematoid  or  hemorrhagic 
sarcoma  is  not  inappropriately  applied  to  them,  or  the  term  fungus 
nematodes  when  they  protrude  through  the  skin.  A  pronounced 
yellowish  color  indicates  fatty  metamorphosis,  which  may  pervade 
almost  the  entire  tumor,  or  be  confined  to  limited  areas  or  to  the  vegeta- 
tions alone,  while  the  remainder  is  white  or  gray,  thereby  imparting  to 
it  a  mottled  aspect.  A  yellowish  tint  also  denotes  myxomatous  changes, 
so  that,  as  in  the  former  instance,  the  mass  of  the  growth  may  be  white, 
or  rosaceous-white,  or  rosaceous-gray,  and  the  vegetations  be  yellow. 
On  the  whole,  however,  gelatinous  spots  dotting  the  surface  of  the  section 
are  the  best  characteristic  of  this  change.  Now  and  then,  or  when  great 
vascularity  and  the  fatty  and  myxomatous  degenerations  are  combined, 
there  will  be  areas  of  yellow  and  red,  and  spots  of  brown  pigmentation, 
along  with  gelatinous  dots.  In  point  of  fact,  the  color  is  so  variable  that 
it  is  extremely  difficult  to  give  an  intelligible  description  of  it.  It  need 
scarcely  be  added  that  melanotic  sarcomata  are  pervaded  by  areas  of 


20 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


dark  brown  or  black  pigmentation.  The  cut  surfaces  of  many  of  the 
largest  specimens  have  also  a  lobed  appearance  from  the  close  packing 
of  the  vegetations  in  the  enlarged  ducts  which  play  the  part  of  capsules. 

The  gross  characters  of  the  smaller  tumors,  which  correspond  to  the 
adenoid  sarcomata  of  Billroth,  and  which  do  not  grow  larger  than  a 
walnut  in  seven  or  eight  months,  are  worthy  of  notice,  as  they  differ 
from  fibromata  of  the  same  dimensions  in  several  particulars  that  are 
useful  in  establishing  a  differential  diagnosis.  Thus,  of  the  five  speci- 
mens of  adenoid  spindle-celled  growths  which  I  have  extirpated,  all 
were  lobulated,  firm,  elastic,  adherent  to  the  gland,  grayish-white  in 
color,  and  tough  on  section.  The  fibromata,  on  the  other  hand,  were 
hard,  merely  nodular,  less  adherent  to  the  mamma,  white,  and  more 
compact  and  tough  on  section.  Under  the  microscope,  the  glandular 
elements  were  undergoing  obliteration  to  a  greater  extent  in  the  former 
than  in  the  latter. 

Inflammation  and  suppuration  of  mammary  sarcoma  are  infrequent, 
but  ulceration  of  the  overlying  tissues  is  so  common  that  it  occurred 
in  twenty-nine,  or  18.59  per  cent.,  of  the  one  hundred  and  fifty-six  cases 
that  I  have  collated,  a  proportion  which  is  more  than  double  that  met 
with  in  fibroma.  As  is  witnessed  in  the  latter  tumor,  the  ulceration 
appears  to  be  the  result  rather  of  inflammation  and  gangrene,  or  merely 
rupture,  of  the  attenuated  skin,  than  of  its  infiltration  by  sarcomatous 
cells ;  but  in  one  case  it  depended  upon  exploratory  puncture.  In  some 
examples  it  is,  doubtless,  due  to  invasion  of  the  skin,  but  only  one  case, 
that  of  a  crater-like  ulcer,  appears  to  have  originated  in  this  way.  In.  10 
per  cent,  of  the  cases  the  ulcer  presents  itself  in  the  form  of  a  sloughing 
patch.  Fungous  protrusion  almost  invariably  follows  the  perforation  of 
the  integuments,  although  in  a  remarkable  instance  recorded  by 
Ashhurst,1  the  recurrent  growth  of  which  I  exhibited  at  the  Pathological 
Society,  the  ulcer  subsequently  healed.  The  protruding  mass,  which  is 
usually  an  intracystic  growth,  varies  in  size  from  a  hazelnut  to  three, 
four,  and  even  five  inches  in  diameter,  and  exhales  a  sanguinolent  and 
fetid  -discharge,  which  may  become  more  or  less  purulent  from  inflam- 
mation induced  by  exposure  and  friction.  It  is  not,  however,  very  prone 
to  free  hemorrhage  or  sloughing.  The  ulcer  itself  is  usually  circular, 
and  the  surrounding  skin  is  not  only,  as  a  rule,  free  from  discoloration, 
but  it  is  also  unattached  to  the  fungus,  and  everted,  or  rather  elevated, 
on  its  sides.  Now  and  then  there  are  several  ulcers,  separated  by 
bridges  of  sound  tissue.  From  a  diagnostic  standpoint,  it  is  worthy  of 
notice  that  ulceration  occurred  in  7.69  per  cent,  of  solid  sarcomata,  against 
18.76  per  cent,  of  cystic  sarcomata,  and  that  it  was  met  with  in  25  per 


1  Trans.  Path.  Soc.  Phila.,  vol..  v.  p.  230. 


GROSS,   SARCOMA   OF   THE   FEMALE  BREAST. 


21 


cent,  of  the  giant- celled,  23.58  per  cent,  of  the  round-celled,  and  17.58 
per  cent,  of  the  spindle-celled  tumors. 

Sarcomata  of  the  breast  are  generally  solitary,  since  I  find  of  one 
hundred  and  fifty-six  cases  that  only  ten  were  multiple,  several  growths 
existing  in  one  gland  in  seven  and  in  both  glands  in  two,  while  in  the 
tenth  instance  four  tumors  were  present  in  one  breast,  and  one  tumor 
was  found  in  its  fellow.  Their  most  common  seat  is  in  the  vicinity  of 
the  nipple,  and,  when  they  arise  from  the  circumference  of  the  organ, 
they  are  usually  found  at  its  upper  and  outer  quadrant.  When  of 
central  origin  they  are,  for  the  most  part,  cystic ;  while  they  are  usually 
solid  when  they  start  from  outlying  lobules.  In  either  event  they 
evince  a  marked  disposition  to  extend  beyond  the  limits  of  their  cap- 
sules, those  of  central  origin  gradually  invading  the  entire  gland,  and 
the  surrounding  soft  parts,  while  the  peripheral  ones  not  only  infect 
the  latter  structures,  but  also  finally  implicate  the  entire  breast.  As  a 
rule  they  give  rise  to  broadly  based  hemispherical  tumors,  but  they  are 
now  and  then  pedunculated. 

They  occur  as  early  as  the  ninth  and  as  late  as  the  seventy -fifth  year, 
the  average  age  of  their  first  observation  being  40.6  years.  Of  148  cases 
in  which  the  age  is  recorded, 


1  appeared 

at 

9  years. 

14 

between  10  and  19 

16 

u 

20   "  29 

40 

a 

30   "  39 

39 

tt 

40   "  49 

23 

50   "  59 

14 

(t 

60   "  69 

1 

at 

75  years. 

Of  the  entire  number  only  4,  or  2.70  per  cent.,  occurred  before  the 
sixteenth  year,  or  during  the  developmental  state  of  the  mamma ;  67, 
or  45.27  per  cent.,  appeared  between  the  sixteenth  and  fortieth  years,  or 
at  a  period  when  the  breast  and  genitalia  are  functionally  most  active ; 
and  77,  or  52.02  per  cent.,  after  the  fortieth  year,  or  during  the  period 
of  their  functional  decline.  Spindle-celled  tumors  develop  earlier  in  life 
than  the  giant-celled  and  round-celled,  since  the  average  age  at  which 
they  were  noticed  was  36  years  and  7  months,  against  47  years  and  3 
months  for  the  giant-celled,  and  48  years  for  the  round-celled.  Unlike 
cystic  and  solid  fibromata,  cystic  sarcomata  appear  at  an  earlier  age  than 
solid  sarcomata,  the  average  for  the  cystic  being  38  years  and  5  months, 
against  43  years  for  the  solid  variety.  Hence  it  may  be  said  that 
spindle-celled  and  cystic  sarcomata  are  metaplasias  of  the  functionally 
perfect  mamma,  and  round-celled,  giant-celled,  and  solid  sarcomata  are 
metaplasias  of  the  declining  gland.  In  point  of  fact,  the  fifteen  sarco- 
mata occurring  before  the  age  of  twenty  were  spindle-celled  in  fourteen. 


22 


GROSS,   SARCOMA    OF   THE   FEMALE  BREAST. 


Thirty-three  of  the  patients  were  single  and  fifty-seven  were  married 
when  the  tumor  was  first  noticed,  while  the  social  condition  is  not  noted 
in  the  remainder.  Of  the  married  women  forty  were  multiparous,  six 
had  one  child,  and  eight  were  barren ;  while  the  question  of  children  is 
not  stated  in  three.  In  two  cases  the  disease  showed  itself  during  preg- 
nancy, and  in  four  soon  after  parturition.  Of  thirty-eight  subjects  in 
which  the  menstrual  function  is  recorded,  all  were  regular  save  one,  who 
suffered  from  amenorrhea.  In  seventeen  instances,  or  one  in  every  nine 
and  one-third,  injury  was  assigned  as  the  cause  of  the  tumor;  in  one  it 
developed  at  the  site  of  an  abscess ;  in  one  it  was  preceded  by  psoriasis 
of  the  nipple ;  while  in  none  was  it  inherited.  These  facts  show  that  the 
etiology  of  sarcomata  is  most  obscure,  since  their  development  is  rarely 
traceable  to  injury  or  disease,  and  is  not  influenced  by  hereditary  pre- 
disposition, while  the  social  state  and  menstrual  irregularities  or  arrest 
are  surely  unimportant  agents  in  their  production. 

The  increase  of  sarcomata  is  more  rapid  than  that  of  the  other  con- 
nective tissue  neoplasms,  but  it  is  liable  to  great  diversity,  being  inde- 
pendent of  the  age  of  the  subject,  and  influenced  by  their  structure,  by 
their  degenerations,  and  by  the  absence  or  presence  of  cysts.  Of  the 
solid  sarcomata  I  have  met  with  six  examples  which  varied  from  one  to 
two  inches  in  diameter  in  five,  six,  seven,  and  eight  months;  and,  even 
at  the  end  of  two  or  three  years,  they  may  not  be  larger  than  an  apricot1 
or  a  turkey's  egg,2  although  they  may,  in  their  pure  state,  attain  the 
«  volume  of  an  adult  head  in  four  months,5  or  a  circumference  of  twenty- 
five  inches  and  a  weight  of  four  pounds  and  two-thirds  in  nine  months/ 
When  they  are  the  seat  of  myxomatous  degeneration  or  of  softening 
cysts,  they  may  weigh  four  pounds  and  twelve  ounces,5  or  measure 
twenty-three  inches  in  circumference  and  weigh  six  pounds,  in  four 
months.6  Of  the  cystic,  as  of  the  solid,  variety,  I  have  seen  examples  in 
which  it  did  not  exceed  a  diameter  of  two  inches  in  five  and  eight 
months ;  while  it  is  rarely  larger  than  a  fist  in  one  year.  In  exceptional 
instances,  however,  it  may  attain  the  volume  of  a  double  fist  in  three 
months,7  or  a  weight  of  upward  of  ten  pounds  in  the  same  number  of 
months,8  or  a  circumference  of  thirty-one  inches  and  a  weight  of  twelve 
pounds  in  one  year.9  As  an  evidence  of  . its  unequal  rate  of  progress,  we 
may  state  that  it  may  require  eighteen  months,10  five  years,11  eighteen 

1  Reverdin  :  Bull,  de  la  Soc.  Anat.,  t.  xlii.  p.  708,  and  t.  xliv.  p.  285. 

2  Zambianchi :  Ibid.,  t.  xlvi.  p.  314.  3  Billroth  :  Chir.  Klinik,  Wien,  1869-70,  p.  142. 
*  Bryant:  Trans.  Path.  Soc.  London,  vol.  xix.  p.  387. 

6  Bennett :  Cancerous  and  Cancroid  Growths,  pp.  12  and  256.  _ 

6  Hewson :  Gross's  System  of  Surgery,  6th  ed.,  vol.  ii.  p.  974. 

7  Post :  Medical  Record,  1^72,  p.  112. 

8  Gliick  :  Langenbeck's  Archiv,  Bd.  viii.  Jahresbericht,  p.  599.  9  Pitha :  Ibid.,  p.  599. 
io  Hubert :  Bull,  de  la  Soc.  Anat.,  t.  xlviii.  p.  690. 

n  Reverdin:  Ibid.,  t.  xliv.  p.  281. 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


23 


years,1  or  forty  years2  to  reach  the  volume  of  a  foetal  head,  or  six  years3 
or  fifteen  years4  to  attain  the  size  of  an  adult  head. 

Like  the  cystic  fibromata,  sarcomata  may  remain  stationary  and  of 
small  dimensions  for  a  long  time,  when,  without  obvious  cause,  they  sud- 
denly begin  to  increase,  so  that  a  nodule  that  has  required  fifteen  years 
to  attain  the  volume  of  a  walnut  reaches  that  of  a  double  fist  in  three 
months  ;5  or  one  which  has  remained  the  size  of  an  egg  for  eighteen  years, 
acquires  the  volume  of  an  adult  head  in  a  few  months  ;6  or  one  that  has 
been  quiescent  and  of  the  size  of  a  walnut  for  twenty -five  years,  suddenly 
begins  to  grow,  and  measures  eighteen  inches  transversely  by  fourteen 
inches  and  a  half  vertically  in  three  years  ;7  or  one  that  has  been  a  year 
and  a  half  in  acquiring  the  volume  of  an  egg  grows  to  a  circumference 
of  twenty-six  inches,  and  a  weight  of  seven  pounds  in  an  additional  six 
months.8  In  such  cases  rapid  accumulation  of  fluid  and  solid  contents 
in  the  dilated  ducts  may  be  looked,  for ;  or  the  increase  in  volume  may 
be  due  to  myxomatous  changes  and  interstitial  hemorrhage.  Under 
similar  circumstances  their  progress  may  be  interrupted,  of  which  I  re- 
cently met  with  a  notable  example.  On  the  11th  of  November,  1886,  I 
removed  a  proliferous  cystic  small  spindle-celled  tumor  from  a  lady  of 
sixty-five.  At  the  age  of  twenty-five,  she  accidentally  observed  a  tumor 
as  large  as  a  chestnut  at  the  inner  side  of  the  right  nipple.    It  remained 


of  that  size  until  the  age  of  sixty- one,  when  it  began  to  grow,  and  during 
the  past  year  had  doubled  its  volume,  so  that  it  was  larger  than  a  foetal 
head.    Its  gross  characters  are  shown  in  the  illustration,  and  the  breast 

1  Pick  :  Trans.  Path.  Soc.  London,  vol.  xx.  p.  347.  2  A  personal  case. 

3  Hubert :  Ibid.,  t.  xlvii.  p.  389.  ♦  Berbeze  :  Ibid.,  t.  xli.  p.  94. 

5  Marignac  :  Bull,  de  la  Soc.  Anat.,  t.  Hi.  p.  428. 

6  Tillaux,  quoted  by  Cordier  :  These  de  Paris,  1880,  No.  494,  p.  1G. 

7  Anderson:  Trans.  Path.  Soc.  London,  vol.  xxiii.  p.  2">4. 

8  Marchand  :  Gaz.  des  Hopitaux,  1809,  No.  51,  p.  196. 


24 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


measured  seven  inches  more  in  circumference  than  its  fellow.  Robin1 
has  recorded  a  case  in  which  a  vegetating  myxomatous  spindle-celled 
tumor  remained  of  the  size  of  a  hazelnut  for  six  years,  when  it  grew 
continuously  for  four  years,  and  reached  the  volume  of  a  fist,  and  then 
doubled  its  size  in  three  years  and  a  half,  and  during  the  last  six  months, 
or  fourteen  years  from  its  first  appearance,  attained  a  weight  of  nine 
pounds.  Tillaux2  extirpated  a  cystic  tumor  which  grew  from  the  size  of 
a  filbert  to  a  hen's  egg  in  three  years,  at  which  size  it  remained  station- 
ary for  four  years,  when  in  six  months  it  acquired  the  volume  of  an  adult 
head.  Although  these  seven  cases  were  examples  of  cystic  tumors,  their 
peculiar  histories  countenance  the  view  held  by  Billroth,  Labbe3  and 
Coyne,4  Konig,5  Duplay,6  and  myself,  that  fibroma  is  frequently  meta- 
morphosed into  sarcoma  through  multiplication  of  its  cells  and  increased 
vascularization.  The  opponents  of  this  view  of  a  change  of  type  may 
urge  that  a  sarcoma  may  remain  latent  for  many  years,  when,  without 
obvious  cause  it  begins  to  grow  rapidly ;  but  there  is  certainly  no  reason 
why  a  fibrous  tumor  should  not  serve  as  the  mother  tissue  of  a  sarcoma 
as  well  as  ordinary  fibrous  tissue.  Be  this  as  it  may,  a  long  period  of 
quiescence  and  intermission  of  growth  are  not  infrequent  in  sarcoma,  and 
are  of  diagnostic  value  when  compared  with  the  progress  of  other  neo- 
plasms of  the  breast.  As  occurs  in  fibroma,  continuous  growth  rather 
indicates  freedom  from  cysts  and  vegetations,  while  sudden  and  rapid 
increase  points  to  fluid  accumulation  and  intracanalicular  vegetations. 

The  growth  of  sarcomata  might  naturally  be  expected  to  be  connected 
with  menstruation,  pregnancy,  or  lactation,  or  with  conditions  which 
render  the  mammary  gland  more  vascular ;  but  the  influence  of  an  in- 
creased flow  of  blood  to  the  organ,  which  has  been  assumed  by  certain 
authors,  is  not  confirmed  by  an  analysis  of  the  cases  that  I  have  collected. 
Thus,  in  only  three  examples  was  an  increase  in  bulk  witnessed  at  the 
menstrual  period,  while  in  two  the  tumor  became  smaller.  In  one  the 
rapid  growth  began  during  pregnancy,  and  in  two  at  the  menopause. 

From  these  considerations  it  follows  that,  while  sarcomata  constitute 
the  most  bulky  of  the  mammary  neoplasms,7  their  growth  is  so  capri- 
cious that  an  average  rate  of  increase  cannot  be  assigned  to  them.  On 
the  whole,  however,  one  is  justified  in  concluding  that  the  small-celled, 

1  Journal  de  l'Anat.  et  de  Phys.,  t.  x.  p.  195,  and  Bull,  de  la  Soc.  Anat.,  t.  xlviii.  p.  817. 

2  Cordier:  These  de  Paris,  1880,  No.  494,  p.  7.  3  Chir.  Klinik.,  Wien,  1871-76,  p.  261. 
*  Traite  des  Tumeurs  Beuignes  du  Sein.,  pp.  269,  283,  and  363. 

5  Lehrbuch  der  Spec.  Chirurgie,  4th  ed.,  Bd.  11,  p.  89. 

6  Traite  Element,  de  Path.  Ext.,  par  Follin  et  Puplay,  t.  v.  p.  628. 

7  In  his  inaugural  dissertation,  Ueber  Fibro-Adenom  der  Mamma,  Gbttingen,  1878,  p.  13,  Watson 
narrates  a  case  from  the  practice  of  Kremer,  in  which  the  tumor  weighed  twenty-two  pounds.  Pean, 
in  his  Lecons  de  Clinique  Chir.,  t.  ii.  p.  90,  describes  a  myxomatous  cystic  spindle-celled  sarcoma  which 
weighed  ten  kilos,  or  more  than  twenty-six  pounds,  and  a  similar  weight  is  recorded  by  Cordier,  in  his 
These  de  Paris,  No.  494,  1880,  p.  40,  from  the  practice  of  Tillaux. 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


25 


the  cystic,  the  myxomatous,  and  the  telangiectatic  increase  more  rapidly 
than  the  large-celled,  the  solid,  and  the  pure  tumors. 

The  active  growth  of  the  sarcomata  is  liable  to  be  attended  with 
marked  elevation  of  the  temperature,  as  was  noted  in  two  of  my  own 
cases,  in  one  of  which  Seguin's  surface  thermometer  indicated  100° 
against  95°  for  the  opposite  breast.  In  two  other  examples  of  cystic 
sarcoma  there  was  an  increase  in  the  heat,  as  roughly  estimated  by  the 
hand.  All  of  these  tumors  were  highly  vascular  and  composed  of  small 
cells,  so  that  elevation  of  the  temperature  may  be  said  to  be  character- 
istic of  telangiectatic  and  rapidly  proliferating  growths.  Further  in- 
vestigations in  this  direction  may  prove  useful  in  determining  the  differ- 
ential diagnosis  of  the  connective  tissue  neoplasms,  and  should  not  be 
neglected. 

During  their  further  progress  sarcomata  continue,  as  a  rule,  mobile 
and  free  from  superficial  or  deep  attachments;  the  contiguous  structures 
are  not  invaded  by  tumor  elements  ;  the  skin  remains  natural  in  color 
and  texture ;  the  subcutaneous  veins  are  not  enlarged ;  the  nipple  is 
normal ;  and  the  associated  lymphatic  glands  are  not  contaminated. 
To  these  general  statements  some  exceptions  must  be  noted. 

a.  While  it  is  not  uncommon  for  recurrent  tumors  to  be  more  or  less 
closely  fixed  to  the  pectoral  muscle,  and  through  it  to  the  walls  of  the 
chest,  it  is  a  singular  fact  that  the  primary  growth  is,  almost  without 
exception,  freely  movable,  and  rarely  attached  even  to  the  common  in- 
tegument. In  a  case  of  spindle-celled  tumor  recorded  by  Zambianchi, 
and  it  was  an  example  of  two  growths  in  the  same  breast,  the  outlying 
tumor  developed  over  the  upper  costal  cartilages  to  which  it  adhered, 
and  sent  a  prolongation  into  the  thorax.1  In  6  additional  instances, 
the  muscles  of  the  chest  were  involved  in  5,  and  the  parammary  fat  in  1. 
The  tumor  was  cystoid  spindle-celled  in  1,  cystic  spindle-celled  in  2, 
round-celled  in  1,  osteoid  round-celled  in  1,  and  cystic  giant-celled  in  1. 
Just  how  often  the  skin  is  invaded  is  difficult  of  solution,  since  in  some 
of  the  cases  of  ulceration  it  was,  doubtless,  converted  into  sarcoma  tissue, 
but  microscopic  data  of  this  fact  are  wanting.  Be  this  as  it  may,  the 
skin  was  adherent  in  15  examples,  of  which  10  were  cystic,  and  5  solid 
tumors,  the  round-celled  slightly  predominating.  If,  in  addition  to  the 
cases  of  invasion  of  the  muscles,  perichondrium,  and  connective  tissue, 
these  15  cases  be  regarded  as  instances  of  invasion  by  tumor  elements, 
sarcomata  of  the  breast  are  to  be  regarded  as  locally  infectious  in  14.19 
per  cent,  of  all  cases. 

Although  the  skin  may  be  stretched  and  attenuated,  and  ulcerated, 

1  Ante  :  Lagrange  and  Duret  (Bull,  de  Soc.  Anat.,  t.  xlviii.  p.  516)  refer  to  a  case  in  which,  on  post- 
mortem examination  of  a  female  who  had  for  many  years  an  enormous  sarcoma  of  the  breast,  the  tumor 
separated  the  fibres  of  the  pectoral  muscles,  passed  between  two  ribs  iuto  the  cavity  of  the  mediastinum, 
and  penetrated  between  and  compressed  the  lobes  of  the  lung,  without  infecting  any  of  these  structures. 


26 


GROSS,   SARCOMA   OF   THE    FEMALE  BREAST. 


as  I  showed  in  18.59  per  cent,  of  all  examples,  it  was  discolored  in  only 
36,  or  in  23  per  cent.,  and  it  is  interesting  to  know  that  the  changes  in 
tint  occurred  twenty-seven  times  in  the  cystic  and  nine  times  in  solid 
growths,  three  of  which  were  the  seat  of  degeneration-cysts,  and  that 
the  round-celled  tumors  predominated.  In  twenty-one  the  tint  was  red, 
in  four  bluish,  in  ten  violaceous,  and  in  one  livid. 

y.  The  superficial  veins  were  enlarged  in  24  instances,  or  in  15.39  per 
cent.,  but  only  to  a  slight  extent  in  2.  In  18  the  tumor  was  cystic,  and 
in  6  it  was  solid,  but  in  the  latter  it  was  the  seat  of  extravasation  of 
blood  in  one,  and  of  mucoid  cysts  in  the  second.  The  spindle-celled 
growths  predominated. 

6.  The  nipple  was  retracted  or  umbilicated  in  only  5,  and  these  were 
examples  of  cystic  growths. 

e.  Of  the  156  cases  the  lymphatic  glands  were  enlarged,  and  now  and 
then  tender,  in  19.  In  14  of  these  the  enlargement  was  associated  with 
the  primary  growth,  but  in  only  1,  a  case  of  alveolar  pigmented  round- 
celled  sarcoma,  were  tumor  elements  detected.1  In  the  remaining  5,  the 
glands  wrere  extirpated  along  with  recurrent  growths,  and  in  2  of  these, 
one  an  example  of  round- celled  sarcoma  communicated  to  me  by  Dr. 
Markoe,  of  New  York,  and  the  second  a  case  of  alveolar  giant-celled 
tumor,2  wTere  they  infected.  Hence  the  glandular  enlargement  wyas  due 
to  irritative  hyperplasia  in  16,  in  10  of  wdiich  ulceration  of  the  tumor 
w7as  present,  while  they  were  infected  in  only  3.  This  immunity  of  the 
glands  from  contamination  is  remarkable,  and  is  a  valuable  sign  in  the 
differential  diagnosis  of  malignant  mammary  growths. 

A  discharge  from  the  nipple  is  not  met  with  in  the  solid  tumors,  but 
occurs  in  one  case  out  of  every  nine  and  a  half  of  cystic  sarcomata,  the 
proportion  being  smaller  than  is  met  with  in  cystic  fibromata,  and  is  of 
great  value  as  a  symptom  of  enlargement  of  the  ducts,  although  it  is  of 
itself  unimportant  in  the  differential  diagnosis.  In  two  instances  from  the 
practice  of  Bryant,3  the  discharge  was  the  first  symptom,  and  preceded 
the  detection  of  the  tumor  by  three  months  in  one  and  by  two  years  in 
the  other  case.  In  a  third  case,  recorded  by  that  surgeon,*  the  flow  wTas 
bloody,  and  derived  from  highly  vascular  vegetations.  In  the  case  of 
Hubert,5  the  tumor  augmented  in  size  at  each  menstrual  period,  when 
there  was  an  occasional  discharge  of  a  citron-colored  liquid.  In  the  ex- 
amples of  Billroth6  and  Winslow,7  in  which  the  neoplasm  developed 
during  pregnancy,  there  was  also  a  spontaneous  escape  of  a  serous  fluid  ; 
while  in  those  of  Lebert8  and  Verneuil,9  a  viscid  transparent  liquid 
was  expelled  by  pressure. 

1  Billroth  :  Die  Krankheiten  der  Brustdrusen,  p.  56.  2  Ibid.,  p.  58. 

3  Guy's  Hospital  Reports,  ser.  3,  vol.  x.  p.  115,  and  ser.  3,  vol.  xxviii.  p.  468. 

*  Ibid.,  vol.  x.  p.  120  5  Bull,  de  la  Soc.  Anat.,  t.  xlviii.  p.  389. 

6  Chir.  Klinik,  Wien,  1869  and  1870,  p.  142.  "  Maryland  Med.  Journ.,  vol.  12,  p.  243. 

8  Physiologie,  Pathologique,  t.  ii.  p.  128  9  Valude  :  These  de  Paris,  1885,  No.  91,  p.  131- 


GROSS,   SARCOMA   OF   THE    FEMALE  BREAST. 


27 


The  growth  of  sarcomata  is  attended  with  pain  in  35.71  per  cent,  of 
all  cases.  In  only  2.67  per  cent.,  however,  was  attention  first  called  to 
the  tumor  by  suffering,  and,  in  the  remainder,  it  declared  itself  later, 
and  varied  in  character  and  frequency  in  accordance  with  the  variety 
of  the  sarcoma.  Thus,  in  the  solid  form  it  was  experienced  in  only 
28  per  cent,  of  the  cases,  and  of  these  it  was  lancinating  and  continuous 
in  42.85  per  cent.,  of  an  occasional  darting  character  in  28.57  per  cent., 
and  lancinating  and  continuous  only  during  the  rapid  increase  of  the 
tumor.  In  the  cystic  variety,  on  the  other  hand,  it  was  felt  in  41.93 
per  cent,  of  the  cases,  and  in  69.23  per  cent,  of  these  it  was,  as  a  rule, 
severe  and  lancinating,  and  came  on  late  in  the  disease,  especially  dur- 
ing rapid  growth,  when  the  tumor  became  tense  through  the  increase 
of  the  contents  of  the  cysts ;  while  it  was  continuous  and  lancinating  in 
11.53.  per  cent.,  and  slight  in  19.23  per  cent.  In  14.28  per  cent,  of  all 
cases  it  wTas  only  experienced  when  ulceration  had  set  in,  but  ulceration 
and  fungous  protrusion  provoked  suffering  in  only  35.72  per  cent,  of  all 
instances,  and  rarely  increased  it  when  it  was  previously  felt.  In  one 
instance  it  was  experienced  only  at  the  menstrual  periods;  while  in 
three  it  was  aggravated,  and  in  one  diminished,  at  that  period.  In  only 
five  cases  was  the  growth  absolutely  tender,  although  in  many  examples 
it  was  annoying  from  its  weight  and  bulk,  so  much  so,  indeed,  in  a  case 
recorded  by  Pick,  that  the  woman  repeatedly  tapped  the  cyst  with  a 
penknife  to  rid  herself  of  these  features. 

During  their  further  progress,  as  we  have  already  seen,  sarcomata 
may  invade  their  limiting  capsules  and  the  neighboring  tissues,  and 
finally  ulcerate.  Without,  however,  of  necessity  pursuing  this  course, 
their  capsules  may  remain  intact,  but  none  the  less  may  they  extend  to 
the  adjacent  structures  along  the  course  of  the  bloodvessels,  the  adven- 
titia  of  which  is  frequently  the  seat  of  small-celled  proliferation,  through 
which  the  tissues  are  converted  into  "latent  zones  of  infection  ;"  these 
zones  are  not  appreciable  by  the  naked  eye,  but  serve  not  only  as  the 
points  of  departure  of  the  recurrences  that  are  so  often  witnessed  after 
their  removal,  but  also  as  foci  of  general  infection  with  the  production 
of  deposits  in  the  internal  organs.  Hence  it  is  that  the  prognosis  of 
sarcomata  is  eminently  unfavorable,  although  there  is  still  no  little 
diversity  of  opinion  among  practical  surgeons  and  pathologists  on  this 
point.  Thus,  Wilks  and  Moxon,1  Cornil  and  Ranvier,2  Labbe  and 
Coyne,3  and  Erich  sen*  regard  them,  and  particularly  the  cystic  form, 
as  being  comparatively  innocent,  and  only  marked  by  a  tendency  to 
local  reproduction.  Labbe  and  Coyne  and  Erichsen  deny  the  possibility 
of  the  general  dissemination  of  spindle-celled  tumors  ;  and  Erichsen, 

1  Lectures  on  Path.  Anatomy,  p.  584,  1875.  2  Manuel  d' Histologic  Pathologique,  p.  1162. 

3  Op.  cit.,  p.  431. 

4  The  Science  and  Art  of  Surgery,  8th  Anier.  ed.,  vol.  ii.  p  710. 


28 


GKOSS,  SAECOMA  OF   THE   FEMALE  BREAST. 


indeed,  advances  the  doctrine  that  "  the  tendency  to  recurrence  will,  in 
most  cases,  gradually  wear  itself  out,  and  after  several  operations  have 
been  required  at  intervals  of  months,  or  a  year  or  two,  the  disease  will 
cease  to  be  reproduced,  and  a  cure  will  be  thus  established ; "  although, 
he  adds,  that  "  instances  are  not  wanting  in  which  the  tendency  to  the 
local  reproduction  of  the  sarcoma  has  been  so  active  that  it  outran  all 
possibility  of  complete  extirpation,  and  eventually  destroyed  the  patient." 
Virchow1  states  that,  while  sarcoma  may  recur  in  loco,  "  it  is  a  tumor  of 
limited  malignity,  but  fully  capable  of  producing  metastases ; "  and 
Liicke2  indorses  this  view.  Birkett,3  Gross,*  Ashhurst,5  Klebs,6  Bill- 
roth,7 Annandale,8  Winckel,9  and  Agnew,10  on  the  other  hand,  fully 
recognize  the  malignant  attributes  of  sarcomata  as  denoted  by  their 
capability  of  reproducing  themselves,  not  only  in  the  neighboring  tissues, 
but  also  in  remote  parts ;  and  other  writers  regard  their  progress  as 
being  "  much  more  favorable  "  than  that  of  mammary  carcinoma. 

The  greatest  obscurity  exists  in  regard  to  the  cystic  sarcomata,  which 
include  the  tumors  in  which  the  dilated  ducts  are  more  or  less  closely 
filled  with  vegetations.  This  uncertainty  is  due  to  the  fact  that  many 
English  and  German  pathologists  and  surgeons  class  cystic  adenomata, 
cystic  fibromata,  and  cystic  myxomata  under  the  term  cystic  sarcoma. 
Marcus  Beck,11  the  latest  writer  on  the  subject,  indeed,  denies  the  pres- 
ence of  duct  cysts  in  sarcoma. 

In  1880  I  certainly  established  the  fact  that  all  the  varieties  of  sarcoma 
of  the  breast  are  malignant;  and  a  careful  study  of  92  of  the  156  cases 
upon  which  this  paper  is  based,  and  in  which  the  final  reports  extend 
beyond  the  mere  statement  of  the  recovery  or  death  of  the  patient,  con- 
firms this  view. 

Of  the  92  cases  only  1  ran  a  natural  course,  it  being  an  example  of 
round-celled  tumor  of  both  breasts,  that  proved  fatal,  with  presumed 
secondary  deposits,  in  seven  months  from  the  first  appearance  of  the 
disease.  The  remaining  91  were  subjected  to  the  knife.  Of  these,  32 
were  well  for  periods  which  varied  between  one  month  and  ten  years  and 
nine  months ;  42  were  marked  by  local  recurrence ;  in  8,  not  only  was 
there  regional  reproduction,  but  metastases  were  found  post-mortem ;  3 
recurred,  with  unmistakable  evidences  of  general  dissemination ;  4  were 
characterized  by  metastases,  and  2  by  presumed  metastases,  without  re- 
currence.   In  other  words,  64.83  per  cent,  of  these  cases  were  endowed 

1  Op.  cit.,  p.  362. 

2  Pitha  and  Billroth's  Hdbch.  der  Allg.  und  Spec.  Chir.,  Bd.  ii.,  Ahth.  i.,  p.  194. 

3  A  System  of  Surgery,  edited  by  Holmes  and  Hulke,  3d  ed.,  vol.  iii.  p.  451. 

4  System  of  Surgery,  6th  ed.,  vol.  ii.  p.  973. 

5  Phila  Med.  Times,  vol.  ix.  p.  384,  1879.  6  Op.  cit.,  p.  1118. 
i  Die  Krankheiten  der  Brustdriisen,  p.  60. 

8  Internat.  Encyclop.  of  Surgery,  vol.  v.  p.  842. 

ft  Lehrbuch  der  Frauenkrankheiten,  p.  754.  10  Princ.  and  Pract.  Surgery,  vol.  iii.  p.  702. 

11  Dictionary  of  Practical  Surgery,  edited  by  Heath,  p.  183. 


GKOSS,  S  A  ECO  MA   OF   THE   FEMALE  BREAST. 


29 


with  malignant  features.  Let  us  examine  these  general  statements  more 
in  detail. 

32  patients  were  alive  and  well  for  an  average  period  of  49  months 
and  10  days  after  operation,  the  disease  having  existed,  on  an  average, 
for  69  months  and  11  days  before  surgical  interference,  so  that  the 
mean  life  of  these  subjects  was  nearly  ten  years.  The  period  of  freedom 
from  recurrence  was 

From  1   to  12  months, 
"     1    "    2  years, 
"     2    "    3  " 
"     3£  "    4  " 
"    4   "   5  " 
For  7  years  and  3  months 


9 
10 
10 
10 
10 


11 

4 
5 
9 


4  cases.1 

4  " 
7  " 

5  " 

1  case. 
1  " 
1  " 
1  " 
1  " 
1  " 
1  " 


As  has  been  seen,  there  was  local  reproduction  in  53  cases.  In  45, 
in  which  the  date  is  noted,  the  periods  of  recurrence  were  as  follows  : 


2 

cases 

in 

3 

weeks. 

3 

cases 

in 

12  months. 

2 

tt 

it 

1 

month. 

1 

case 

(C 

15 

tt 

7 

<t 

It 

2 

months. 

1 

tl 

17 

a 

3 

tt 

tt 

3 

u 

2 

cases 

a 

18 

a 

2 

tt 

tt 

3* 

tt 

1 

case 

a 

20 

a 

2 

tt 

tt 

4 

tt 

1 

a 

n 

21 

it 

5 

tt 

5 

tt 

3 

cases 

(C 

24 

a 

3 

ft 

a 

6 

it 

1 

case 

a 

29 

u 

1 

case 

it 

7 

a 

1 

u 

<  t 

32 

tt 

1 

it 

tt 

8 

it 

1 

cc 

(C 

36 

tt 

1 

a 

tt 

9 

a 

1 

a 

tt 

48 

The  table  shows  that  more  than  one-half,  or  57.7  per  cent.,  of  the  re- 
productions took  place  in  6  months,  while  after  12  months  there  were 
only  13,  or  28.8  per  cent.,  and  of  these  there  were  only  4,  or  8.8  per 
cent.,  after  2  years.  These  statements  lead  to  the  belief  that  the  chances 
for  the  patient  are  relatively  good  after  the  lapse  of  2  years,  and  that 
the  prognosis  is  all  the  more  favorable  as  the  period  of  freedom  from 
signs  of  local  contamination  prolongs  itself.  As  the  latest  date  of  repro- 
duction was  4  years,  we  may  assume  that  the  12  cases  of  the  first  table 
which  remained  well  after  the  lapse  of  that  time  were  permanently 
cured.  The  average  date  of  recurrence  was  101  months,  and  the  total 
life  of  these  patients  from  the  first  observation  of  the  disease  to  the  final 


1  The  shortest  periods  were  1  month,  4,  6,  and  10  n  onths. 


30 


GROSS,   SARCOMA   OF   THE   FEMALE  BREAST. 


report  after  the  last  operation  was  7  years  and  9  months.  The  number 
of  recurrences,  or  operations  for  recurrence,  was  1  in  23  cases,  2  in  13 
cases,  3  in  7  cases,  4  in  1  case,  5  in  4  cases,  6  in  2  cases,  7  in  1  case,  12 
in  1  case,  and  22  in  1  case. 

While  the  average  was  10?  months,  the  histological  constitution  of 
the  growth  appears  to  have  exerted  a  marked  influence  upon  the  date 
of  recurrence.  Thus,  the  average  date  of  local  reproduction  was  4 
months  and  20  days  for  the  round-celled,  11  months  and  27  days  for  the 
spindle-celled,  and  12  months  and  10  days  for  the  giant-celled.  The 
cystic  tumors  recurred  in  8  months  and  5  days,  and  the  simple  in  13 
months  and  9  days,  and  this  contrast  becomes  the  more  striking  when 
we  state  that  the  average  date  of  recurrence  for  cystic  round-celled 
growths  was  3  months  and  4  days  as  against  6  months  and  8  days  for 
the  simple  round-celled,  and  9  months  for  cystic  spindle-celled  as  against 
16  months  for  the  simple  spindle-celled. 

Of  the  91  cases  metastatic  growths,  as  demonstrated  post-mortem, 
or  by  unmistakable  evidences  during  life,  had  formed  in  17,  or  18.68 
per  cent.  There  can  be  no  doubt  that  this  estimate  is  too  low,  since  of 
20  examinations  of  persons  dead  from  the  effects  of  the  primary  opera- 
tion, or  dead  after  secondary  operations,  metastatic  growths  were  found 
in  12,  or  60  per  cent.  The  total  duration  of  life  from  the  first  appear- 
ance of  the  primary  tumor  to  the  death  of  the  17  patients  was  57  months, 
9  months  having  been  the  shortest,  and  25  years  and  7  months  the 
longest,  period.  The  relative  frequency  of  the  seats  of  the  secondary 
deposits  is  shown  by  the  following  statement : 

Lungs,  in  10  cases.  Pleura,   in  1  case. 

Liver,  "  4    "  Heart,     "  1  " 

Brain,  "  3    "  Kidney,  "  1  " 

Dura  mater,  "  1  case.  Muscles,  "  1  " 

Eetroperitoneal  glands "  1    "  Bones,     "  1  " 

Mediastinum,  "  1  " 

The  prognosis  is  materially  influenced  by  the  age  of  the  patient  and 
by  the  size  and  rate  of  increase  of  the  tumor.  Thus  before  the  age  of 
thirty-five,  when  the  mammary  gland  is  functionally  most  active,  a  small, 
slowly  growing  sarcoma  does  not  return,  while  a  rapidly  increasing  tumor, 
especially  the  cystic  variety,  is  very  liable  to  recur.  Among  the  latter 
class  of  cases,  60.71  per  cent,  were  characterized  by  recurrence,  and  10.71 
per  cent,  by  metastatic  tumors.  Of  these,  the  solid  sarcomata  recurred  in 
53.84  per  cent.,  and  gave  rise  to  secondary  growths  in  7.69  per  cent.,  while 
the  cystic  recurred  in  per  cent.,  and  were  marked  by  metastases  in 

13.33  per  cent.  It  does  not  appear,  however,  as  many  writers  assert,  that 
the  more  tender  the  age  the  more  rapid  is  the  growth  of,  and  the  more 
malignant  is,  the  neoplasm.  Thus,  of  15  cases,  the  ages  of  which  varied 
from  9  to  19  years,  or  16-1-  years  on  an  average,  the  tumor  had  been  in 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


31 


existence  on  an  average  for  7^  years  before  its  removal,  and  28.57  per 
cent,  remained  well,  while  71.43  per  cent,  recurred,  and  metastases  were 
not  observed  in  a  single  instance.  After  the  thirty-fifth  year,  on  the 
other  hand,  and  the  danger  increases  with  advancing  age,  the  greater 
is  the  liability  to  metastases,  as  in  this  class  of  cases  19.35  per  cent,  were 
generalized,  and  43.54  per  cent,  recurred.  Of  these,  the  solid  tumors 
recurred  in  47.05  per  cent.,  and  gave  rise  to  secondary  growths  in  23.54 
per  cent.,  while  the  cystic  recurred  in  44  per  cent.,  and  were  marked  by 
metastases  in  16  per  cent,  of  all  cases.  In  other  words,  a  sarcoma  occur- 
ring in  a  functionally  active  breast  evinces  a  marked  disposition  to  recur 
after  operation,  with  less  disposition  to  metastases,  while  a  sarcoma  of  the 
declining  breast  recurs  less  frequently,  but  is  generalized  in  a  greater 
number  of  instances. 

The  prognosis  is  also  influenced  by  the  histological  constitution  and 
the  stage  of  evolution  of  the  tumor.  Of  the  spindle-celled  65.10  per 
cent,  recur,  and  20.40  per  cent,  give  rise  to  metastatic  growths ;  of 
the  round-celled  60  per  cent,  recur,  and  25  per  cent,  are  generalized ; 
of  the  giant-celled  57.14  per  cent,  recur,  and  in  none  are  there  metas- 
tases ;  of  the  solid  64.58  per  cent,  recur,  and  25  per  cent,  are  dis- 
seminated;  while  of  the  cystic  51.16  per  ceut.  recur,  and  11.62  per 
cent,  are  generalized.  Hence,  while  the  round- celled  are  the  most 
maliguant,  the  metastasis  of  the  spindle-celled  is  by  no  means  to  be 
denied,  nor  can  we  say,  with  certain  writers,  that  the  cystic  variety  is  an 
innocent  tumor,  or  one  of  limited  malignity,  since  it  recurs  in  more  than 
one-half  of  all  cases,  and  generalizes  itself  in  about  one  case  out  of  every 
nine.  These  investigations  demonstrate  that  the  usual  statements,  which 
are  so  opposed  to  the  actual  facts,  as  to  the  malignity  of  sarcomata,  are 
due  either  to  their  not  having  been  based  upon  a  careful  analysis  of  a 
sufficient  number  of  recorded  cases,  confirmed  by  minute  examination, 
or  to  the  confounding  of  cystic  sarcomata  with  other  cystic  growths, 
which  never  infect  the  economy. 

While  I  have  been  unable  to  collate  cases  in  which  the  disease  ran  a 
natural  course,  through  which  we  are  deprived  of  data  bearing  upon  the 
duration  of  life  in  this  class  of  patients,  and  comparing  them  with  the 
average  duration  of  life  of  those  subjected  to  the  knife,  there  can  be  no 
doubt  that  operations  do  result  in  permanent  recoveries,  and  prolong  life, 
even  if  a  final  cure  is  not  attained.  From  an  inspection  of  the  two  tables 
on  a  previous  page,  it  appears  that  recurrence  may  be  delayed  for  four 
years,  and  that  12  subjects  were  alive  and  well  after  four  years,  so  that 
if  we  take  four  years  as  the  criterion  of  safety,  the  91  operations  show 
13.18  per  cent,  of  cures. 

Although  the  recurrent  regional  disease  is  more  intense  than  the 
primary,  and  other  reproductions  generally  follow  in  quick  succession, 
the  removal  of  tumors  as  fast  as  they  appear  certainly  alleviates  sutler- 


'62 


GKOSS,  SARCOMA  OF   THE   FEMALE  BREAST. 


ing,  prolongs  life,  averts  visceral  contamination,  and  occasionally  brings 
about  a  cure.  Thus,  Bryant1  removed  the  entire  breast  for  a  round- 
celled  sarcoma  on  January  9,  1883,  and  up  to  February  10,  1886,  per- 
formed twelve  operations  for  multiple  recurrent  growths,  the  opposite 
breast  being  the  seat  of  an  atrophic  scirrhus  of  sixteen  years'  standing. 
Billroth2  enucleated  a  cystic  sarcoma,  and  removed  four  recurrent 
growths  in  four  years,  the  breast  being  extirpated  at  the  last  operation, 
and  the  woman  was  free  from  disease  three  years  subsequently. 
Erichsen3  extirpated  the  entire  breast  for  a  cystic  growth  of  twenty- 
seven  years'  standing  in  1859,  and  removed  recurrent  growths  in  1861, 
1863,  1864,  1865,  and  1866,  death  ensuing  from  paralysis  "  some  years 
after  the  last  operation."  In  Heath's  *  case  of  removal  of  the  gland  for 
a  spindle-celled  tumor,  six  operations  for  recurrences  were  done  in  thir- 
teen years,  and  the  patient  was  alive  with  a  seventh  recurrence.  In 
that  of  Haward,5  a  spindle-celled  tumor  was  removed  in  1860,  and 
recurrent  growths  were  excised  in  1863,  1869,  and  1873.  The  patient 
died,  without  metastases,  from  the  effects  of  the  last  operation,  but  life 
was  prolonged,  as  in  the  preceding  instance,  for  thirteen  years.  Riedel8 
removed  six  recurrences  in  twenty  years  following  an  operation  for  giant- 
celled  sarcoma,  and  on  death  there  were  no  metastases.  Gay,7  in  May, 
1865,  enucleated  from  the  same  breast  two 'cystic  spindle-celled  sarco- 
mata of  six  years'  standing.  Recurrent  growths  were  removed  in  July, 
1867,  with  the  entire  gland,  in  May,  1869,  and  May,  1874,  in  June, 
1878,  in  May,  1880,  and  in  June,  1881,  so  that  life  was  extended  for 
fourteen  years,  and  the  woman  was  still  living  at  the  date  of  the  last 
report.  The  case  of  S.  D.  Gross,8  however,  is,  so  far  as  I  know,  the 
most  remarkable  on  record.  In  March,  1857,  a  single  woman,  aged 
forty-four,  discovered  a  small  tumor  in  the  left  breast,  which,  on  enuclea- 
tion the  following  October,  proved  to  be  a  small  spindle-celled  sarcoma. 
During  the  next  sixteen  months  two  more  partial  operations  were  per- 
formed, and  a  fourth  tumor,  along  with  the  entire  breast,  was  extir- 
pated in  May,  1859.  In  three  months  and  a  half  the  knife  was  again 
required,  and  soon  afterward  other  tumors  were  removed.  In  1860 
she  underwent  eleven  operations,  and  six  in  1861,  the  last  of  which 
was  performed  in  September  of  that  year,  so  that  she  was  subjected 
to  twenty-two  operations  for  fifty-one  recurrent  tumors  in  four  years. 
They  varied  in  size  from  an  almond  to  a  hen's  egg ;  appeared  at  or 
near  the  cicatrices  in  a  few  weeks,  and  rapidly  assumed  a  fungating 

1  Private  communication,  March  6,  1886.  2  Die  Krankheiten  der  Brustdrusen,  p.  68. 

3  The  Science  and  Art  of  Surgery,  8th  Amer.  ed  ,  vol.  ii.  p.  711. 

4  British  Medical  Journal,  1878,  vol.  i.  p.  194.  5  Trans.  Clin.  Soc.  London,  vol.  vii.  p.  106. 

6  Centralblatt  fur  Chirurgie,  1881,  Bd.  8,  p.  636. 

7  Trans.  Path.  Soc.  London,  vol.  xvi.  p.  240;  vol.  xx.  p.  359;  vol.  xxv.  p.  233;  vol.  xxxi.  p.  272; 
and  vol.  xxxiii.,  Suppl.  p.  24. 

8  A  System  of  Surgery,  6th  ed.,  vol.  ii.  p.  974. 


GROSS,  SARCOMA  OF  THE   FEMALE  BREAST. 


33 


aspect.  Large  portions  of  the  pectoral,  and  also  of  the  external  and 
internal  intercostal  muscles  were  cut  away,  so  that  during  a  deep  in- 
spiration there  was  a  slight  protrusion  of  the  pleura.  Ten  years  and 
nine  months  after  the  last  operation  she  was  in  perfect  health.  In  these 
eight  cases  there  was  no  lymphatic  involvement,  and  the  general  health 
was  unimpaired. 

A  study  of  the  preceding  facts  shows  that,  like  carcinoma,  sarcoma  is 
a  malignant  growth.  It  differs,  however,  from  the  former  in  many  im- 
portant features,  which  are  shown  in  the  following  statement : 

Sarcoma.  Carcinoma 

Invasion  of  the  skin  by  tumor  elements      .    9.67  per  cent.  68.92  per  cent. 

Invasion  of  the  chest  walls  .       .      .       .    3.87       "  21.58  " 

Invasion  of  the  parammary  connective  tissue   0.64       "  8.39  " 

Primary  invasion  of  the  axillary  glands      .    0.64       "  67.35  " 

Local  reproduction  after  removal       .       .  58.24      "  80.97  " 

Metastases  found  post-mortem    .       .       .  60.00       "  50.00  " 
Average  duration  of  life      ....      81  months.         39  months. 

Permanent  cures  .       .       .  .       .  13.18  per  cent.  10.39  per  cent. 

From  this  table  it  appears  that  sarcoma  is  less  infectious  locally,  but 
more  infectious  as  regards  the  general  system,  than  carcinoma.  Its 
more  relatively  benign  character  is  shown  not  only  by  the  larger  pro- 
portion of  cures,  but  also  by  the  fact  that  the  average  duration  of  life, 
from  the  first  observation  of  the  disease  to  the  date  of  the  last  removal 
after  operation,  is  forty-two  months  longer ;  and  this  contrast  becomes 
the  more  striking  when  it  is  stated  that  the  majority  of  the  sarcomatous 
patients  were  still  living,  and  the  majority  of  the  carcinomatous  subjects 
were  dead.  Not  only  is  this  statement  true  for  sarcomata  in  general, 
but  it  holds  good  for  the  three  varieties,  since  the  average  life  for  round- 
celled  sarcoma  is  fifty- four  months,  ninety  months  for  the  spindle-celled, 
and  one  hundred  and  eight  months  for  the  giant-celled. 

The  diagnosis  of  small,  slowly  increasing  fibrous  sarcomata  is  by  no 
means  easy,  as  they  are  very  liable  to  be  confounded  with  fibromata,  par- 
ticularly when  they  arise  at  the  circumference  of  the  mamma.  A  tumor, 
however,  of  soft,  apparently  fluctuating  consistence,  with  elevated  tem- 
perature, conveying  the  impression  of  an  abscess,  and  occurring  in  young 
women,  which  attains  a  large  volume  in  a  few  months,  can  scarcely  be 
anything  else  than  a  medullary  sarcoma.  On  the  whole,  the  diagnosis 
is  based  upon  their  indolent  origin,  mobility,  elastic,  or  unequal  consist- 
ence, lobulated  outline,  rapid  increase,  freedom  from  lymphatic  involve- 
ment, their  tendency  to  ulcerate,  the  not  infrequent  discoloration  of  the 
skin,  and  enlargement  of  the  subcutaneous  veins,  and,  possibly,  elevation 
of  temperature;  upon  the  suffering  which  they  awaken  late  in  the  dis- 
ease ;  and  upon  their  greatest  frequency  after  the  fortieth  year. 

The  only  tumors  met  with  before  the  age  of  sixteen  are  fibromata  and 

NO.  CLXXXVII. — JULY,  1887.  3 


34 


GBOSS,  SARCOMA  OF  THE  FEMALE  BEEAST. 


sarcomata,  the  former  being  twice  as  common  as  the  latter.  The  fibromata 
are  always  solid,  and  grow  slowly,  while  the  sarcomata  are  cystic  in  three- 
fourths  of  all  instances,  and  medullary  in  the  remaining  fourth,  and,  as 
a  rule,  grow  rapidly.  Hence  cystic  and  medullary  tumors  at  this  period 
of  life  are  sarcomata  and  nothing  else. 

Between  the  spindle-celled,  round-celled,  and  giant- celled  there  are 
some  marked  similarities  which  render  their  differentiation  difficult.  The 
spindle-celled,  however,  are  characterized  by  their  development  at  a 
comparatively  early  age ;  by  the  attendant  suffering ;  by  the  enlarge- 
ment of  the  subcutaneous  veins ;  by  their  slow  reproduction  after  re- 
moval ;  and  by  their  long  life.  The  round-celled,  on  the  other  hand, 
appear,  as  a  rule,  at  a  comparatively  late  age,  and  are  painless ;  but  the 
skin  is  liable  to  be  discolored  and  ulcerated,  and  recurrence  is  rapid,  and 
the  duration  of  life  is  relatively  short.  The  giant-celled  likewise  appear 
late  in  life,  but  are  painful ;  discoloration  of  the  skin  and  ulceration  are 
also  common ;  but  there  is  no  enlargement  of  the  veins,  while  irritative 
enlargement  of  the  axillary  glands  is  frequent.  Local  reproduction  is 
delayed  longer  than  in  the  other  varieties,  and  the  duration  of  life  is 
remarkable. 

These  points  are  set  forth  in  the  following  table,  in  w7hich  the  affinities 
and  contrasts  of  the  three  principal  varieties  may  be  seen  at  a  glance : 


Spindle-celled. 

Round-celled. 

Giant-celled. 

Average  age  of  appearance  . 

36  years. 

48  years. 

47  years. 

Appear  before  16th  year 

12.08  per  ct. 

0.83  per  ct. 

0  per  ct. 

Pain  

60.00  " 

10.81  " 

43  " 

Skin  discolored  .... 

20.88  " 

32.35  " 

25  " 

Ulceration  

17.58  " 

23.58  " 

25  " 

Veins  enlarged  .... 

17.58  " 

11.76  " 

0  " 

Glands  swollen  .... 

6.59  " 

8.82  " 

37.5  " 

Glands  infected  .... 

0. 

2.94  " 

0.  " 

Adjacent  tissues  invaded 

•13.18  " 

17.64  " 

25  " 

Local  reproduction 

65.10  " 

60. 

57.14" 

"                    average  date  of 

12  months. 

4|  months. 

12J  mos. 

Metastatic  deposits 

20.40  per  ct. 

25  per  ct. 

0  per  ct. 

Average  life  with  operation  . 

90  months. 

54  months. 

108  mos. 

Between  the  solid  and  cystic  varieties  there  are  certain  distinctions, 
which  are  useful  in  establishing  a  differential  diagnosis.  The  former 
develop  at  about  the  forty-third  year  ;  the  skin  is  discolored  in  11.53  per 
cent ;  ulceration  occurs  in  7.69  per  cent. ;  the  veins  are  dilated  in  7.69 
per  cent. ;  there  is  no  discharge  from  the  nipple,  nor  is  it  retracted  ; 
pain  is  met  with  in  28  per  cent. ;  the  surrounding  tissues  are  invaded  by 
tumor  elements  in  11.54  per  cent.;  the  lymphatic  glands  are  enlarged 
in  11.54  per  cent.,  and  infected  in  1.28  per  cent.;  recurrence  ensues 
in  64.58  per  cent.,  and  metastatic  growths  are  met  with  in  25  per  cent, 
of  all  instances.    Cystic  sarcoma  starts,  as  a  rule,  at  the  thirty-eighth 


GROSS,  SARCOMA   OF   THE   FEMALE  BREAST. 


35 


year,  and  is  not,  as  is  asserted  by  many  writers,  most  common  between 
twenty  and  thirty-five  years,  as  just  as  many  cases  occur  after  as  before 
the  latter  age;  it  grows  more  rapidly  than  the  solid  variety,  and  its 
increase  is  often  sudden  after  having  remained  stationary  or  advanced 
slowly  for  some  time.  ISTow  and  then,  after  evacuation  of  the  fluid  of 
the  superficial  cysts,  their  solid  contents  can  be  detected  by  manipu- 
lation ;  their  consistence  is,  as  a  rule,  unequal,  and  they  are  more  largely 
lobulated  than  the  former  variety.  The  skin  is  discolored  in  34.61  per 
cent. ;  the  tumor  ulcerates  in  18.76  per  cent ;  the  veins  are  enlarged  in 
23.07  per  cent. ;  the  nipple  is  retracted  in  6.41  per  cent.,  and  discharges 
fluid  in  10.25  per  cent ;  pain  is  experienced  in  41.93  per  cent. ;  the  adja- 
cent tissues  are  infected  in  16.66  per  cent. ;  the  lymphatic  glands  are 
swollen  in  5.12  per  cent.,  but  they  are  never  invaded  by  tumor  elements  ; 
while  it  recurs  in  51.16  per  cent.,  and  becomes  generalized  in  11.62  per 
cent,  of  all  cases. 

There  are  no  signs  by  which  cystic  sarcomata  can  be  absolutely  differ- 
entiated from  cystic  fibromata,  with  which  they  are  so  frequently  con- 
founded. The  latter  develop  earlier  in  life,  and  a  discharge  from  the 
nipple  is  more  common  than  in  the  former ;  but  ulceration  and  enlarge- 
ment of  the  veins  are  only  one-half  as  frequent,  and  they  are  not  attended 
with  glandular  enlargement  or  malignant  features.  It  should,  however, 
be  stated  that  the  largest  proliferous  cystic  tumors  met  with  in  old, 
married  multiparas  are  generally  sarcomata 

As  no  attempt  has  hitherto  been  made  to  describe  the  life  history  of 
the  giant-celled  variety,  and  some  of  the  modified  forms  of  mammary 
sarcoma,  the  following  facts  will  be  found  to  be  not  devoid  of  interest. 

In  8  cases  of  giant-celled  tumors  that  I  have  collated,  the  average  date 
of  their  first  observation  was  47J  years,  or  at  the  ages,  respectively,  of 
42,  45,  45,  46,  46,  49,  50,  and  55.  Of  the  6  cases  in  which  the  social 
condition  is  noted,  3  were  married,  of  which  2  were  parous,  and  3  were 
single.  The  tumors  were  solid  in  6,  of  which  one  was  alveolar,  and 
cystic  iu  2.  The  skin  was  violaceous  in  tint  and  adherent  in  one  case  of 
cystic  tumor,  and  red  and  stretched  in  one  of  solid  tumor.  In  one  of 
the  cystic  tumors  there  was  firm  attachment  to  the  great  pectoral  muscle. 
Ulceration  was  met  with  in  3,  of  which  2  were  solid  and  1  was  cystic. 
The  axillary  glands  were  enlarged  but  not  infected  in  3  cases,  2  of 
which  were  cystic  and  1  was  solid,  and  enlarged  lymphatic  glands 
were  detected  in  3  cases  of  recurrence  of  solid  tumors,  in  1  of  which, 
an  alveolar  growth,  they  were  invaded  by  tumor  elements. 

All  of  the  cases  were  subjected  to  the  knife.  In  1  the  history  ceases 
with  the  operation.1  In  3  there  was  no  recurrence,  and  the  patients 
were  alive  subsequently  for  ten  years  and  five  months,2  three  months,3 

i  Estlander  :  Rev.  Mens,  de  Med.  et  de  Chir.,  4,  1880,  p.  T96.  2  Ibid.,  p.  79G. 

3  Lancereaux :  Bull,  de  la  Soc.  Anat.,  t.  xxxv.  p.  292. 


36         GROSS,  SAKCOMA   OF  THE  FEMALE  BREAST. 

and  ten  years.1  In  4  the  tumor  recurred.  In  Billroth's2  case,  a  repro- 
duction, with  infected  glands,  was  removed  in  two  months,  and  another 
similar  operation  was  performed  in  a  few  months.  The  patient  died  of 
erysipelas,  but  metastases  were  not  found  post-mortem.  In  the  case  of 
Riedel,3  six  recurrent  growths  were  removed  in  twenty  years,  and  on 
death  it  was  found  that  the  patient  was  free  from  metastases.  In  the 
case  of  Estlander,4  a  recurrent  growth,  along  with  the  glands  of  the 
axilla,  was  removed  in  two  years  and  five  months,  and  the  patient  was 
well  five  years  and  nine  months  subsequently ;  while  in  the  case  of 
Stanley,5  the  patient  died  with  a  recurrent  tumor  in  two  years  after  the 
extirpation  of  the  breast.  The  average  total  duration  of  life  of  these 
patients  from  the  first  observation  of  the  disease  to  the  final  report  was 
nine  years. 

It  will  thus  be  seen  that  giant-celled,  or  myeloid,  sarcoma  sets  up  irri- 
tative enlargement  of  the  lymphatic  glands  in  37.5  per  cent,  of  all  cases; 
that  the  skin  is  discolored,  the  tumor  ulcerated,  and  the  surrounding 
tissues  are  infected  in  25  per  cent.;  that  the  subcutaneous  veins  and 
nipple  are  normal ;  and  that,  while  it  recurs  in  57.14  per  cent.,  it  never 
gives  rise  to  metastatic  growths. 

Osteoid  sarcoma,  or  the  variety  which  contains  true  osseous  tissue,  has 
been  met  with  at  the  ages  of  27, 46,  49,  and  51  years,  the  average  being 
43  years.  It  occurs  usually  in  married  multipart ;  as  a  rule  grows 
slowly ;  is  hard,  except  when  it  has  undergone  cystoid  degeneration ; 
acquires  large  dimensions  in  one-half  of  the  cases,  and  is  painful  during 
its  rapid  growth.  It  ulcerates  in  one-fourth  of  all  instances ;  invades 
the  adjacent  tissues  in  one-half;  does  not  infect  the  lymphatic*  glands, 
nor  is  it  marked  by  dilatation  of  the  superficial  veins. 

The  case  recorded  by  Durham6  is  devoid  of  further  history.  Of  the 
three  reported  by  Stilling,7  in  which  an  operation  was  practised,  one 
died  in  twenty-three  months,  without  recurrence,  but  with  evidences  of 
metastatic  growths  in  the  lungs  and  pleurae ;  one  died  of  pneumonia  on 
the  third  day,  with  secondary  tumors  of  the  lungs,  and  sarcomatous 
thrombosis  of  the  veins  of  the  pectoral  muscle,  the  disease  having  existed 
for  eighteen  months;  and  the  third  was  characterized  by  two  local 
reproductions,  and  a  metastatic  growth  of  the  left  ventricle  of  the  heart, 
about  sixteen  weeks  after  the  primary  operation,  the  total  life  having 
been  ten  years  and  four  months.  The  average  life  of  these  cases  from 
the  first  observation  of  the  disease  until  its  termination  was  fifty-seven 
months,  and  the  average  life  after  operation  was  thirteen  months  and  a 

1  Paget :  Trans.  Clin.  Soc.  London,  vol.  vii.  p.  108. 

2  Die  Kn  akheiten  der  Brustdrilsen,  p.  58. 

3  Centralblatt  fur  Chirurgie,  1881,  No.  40,  p.  636.  *  Ut  supra. 

5  Paget:  Lect.  on  Surg.  Path.,  3ded.,  p.  555. 

6  Trans.  Path.  Soc.  London,  vol.  xxxv.  p.  378. 

7  Deutsche  Zeitschrift  fur  Chirurgie,  Bd.  xv.  pp.  247-253. 


MACDOUGALL,  VALUE  OF  BLOODLETTING. 


37 


half.  Hence,  metastases  occurred,  or  were  presumed  to  have  occurred, 
in  all  the  cases,  and  of  those  who  survived  the  knife  local  reproduction 
was  witnessed  in  one-third,  and  a  recurrent  growth  would  certainly 
have  been  formed  if  the  patient  with  sarcomatous  pectoral  veins  had 
survived.  From  these  considerations,  osteoid  sarcoma  must  be  regarded 
as  the  most  malignant  of  the  mammary  sarcomata. 

The  life  history  of  pigmented  alveolar  round-celled  sarcoma  can  only 
be  based  upon  two  cases.  In  that  of  Billroth,1  a  hard  tumor,  of  three 
years'  duration,  as  big  as  a  child's  head,  and  adherent  to  the  skin,  was 
removed,  along  with  infected  glands,  from  a  multipara  sixty -five  years  old. 
The  patient  died  of  exhaustion,  without  recurrence,  in  eight  months,  but 
there  was  no  post-mortem  examination.  In  the  case  of  Butlin,2  a  tumor 
of  seven  years'  standing  was  removed,  in  1880,  from  the  otherwise  normal 
breast  of  a  woman  of  fifty-eight.  Recurrent  growths  were  extirpated  in 
1882, 1884,  and  1886,  but  the  history  ceases  with  the  last  operation.  In 
addition  to  these  cases,  Wacker3  describes  a  case  of  multiple  melanotic 
alveolar  round-celled  sarcoma  of  both  breasts,  with  infection  of  the 
glands  of  the  left  axilla,  and  metastatic  tumors  of  the  spleen,  mesen- 
teric glands,  and  brain.  The  disease  was  thought  to  be  secondary  to 
melanotic  sarcoma  of  the  skin  of  the  mammae.  Winckel  depicts  a 
proliferous  myxomatous  melanotic  sarcoma,  but  the  case  is  devoid  of 
history.4 

The  treatment  may  be  summed  up  in  a  few  words.  The  entire  breast 
along  with  any  skin  that  may  be  invaded,  must  be  extirpated,  especial 
care  being  paid  to  the  complete  removal  of  every  particle  of  parammary 
fat  and  -  the  fascia  of  the  pectoral  muscle,  in  which  tissues  experience 
shows  that  recurrence  takes  place.  In  the  event  of  repullulation  the 
growths  should  be  freely  excised  as  fast  as  they  appear,  as  such  a 
practice  not  only  prolongs  life,  but  may  bring  about  a  final  cure. 


ON  THE  REMEDIAL  VALUE  OF  BLOODLETTING. 
By  J.  A.  Macdougall,  M.D.,  F.R.C.S.  Ed., 

CONSULTING  SURGEON   TO   THE   CUMBERLAND   INFIRMARY,  ETC. 

It  has  often  seemed  to  me  a  matter  of  regret  that  a  remedy  of  such 
unquestionable  power  as  bloodletting  should,  from  former  abuse,  be 
reckoned  by  many  as  among  the  things  of  the  past,  and  that  it  should 
have  run  the  risk  of  being  denied  all  virtue,  because  of  some  inherent 


i  Op.  cit.,  p.  56,  fig.  57. 

3  Inaug.  Disser.,  Rostock,  1884,  p.  15. 


2  Lancet,  January  8,1887,  p.  72. 

*  Lehrbuch  der  Frauenkrankheiten,  p.  756. 


38  MACDOUGALL,  VALUE  OF  BLOODLETTING. 

faults,  which,  however,  are  quite  capable  of  compensation.  Its  very 
power,  and  the  exact  results  which  in  fitting  cases  attend  its  employment, 
doubtless  led  to  its  indiscriminate  use,  and,  inasmuch  as  it  is  spoliative 
in  its  nature — a  power  fraught,  it  may  be,  with  the  greatest  evil — it  is 
not  difficult  to  see  how  readily  it  might  be  abused.  The  dangers  attaching 
to  this  abuse  once  fully  recognized,  the  extreme  oscillation  was  readily 
foretold,  for  in  medicine,  as  in  the  sciences,  which  are — maybe — more 
exact,  the  pendulum  of  opinion  swings  freely  and  its  resting  points  may 
be  very  widely  distant. 

Bloodletting  is  not  the  only  form  of  treatment  to  which  time  and 
increase  in  knowledge  have  carried  wise  modifications.  Thirty  years 
ago  there  developed  what  many  now  regard  as  a  craze  for  alcohol-giving, 
and  when  we  note  the  position  it  held  then,  and  call  to  remembrance 
that  which  it  holds  now,  we  may  almost  cherish  a  hope  that  a  power  as 
valuable,  and  not  more  difficult  to  handle,  may  again  take  a  recognized 
position  as  a  valuable  remedy.  With  that  greater  skill  which  is  un- 
doubtedly ours,  with  that  more  intimate  acquaintance  with  physiological 
and  pathological  processes,  we  are  better  able  to  judge  the  exact  capa- 
bility of  such  a  remedy,  and  when  we  recognize  in  it  the  power  to  modify 
the  distribution  of  the  blood,  and  to  diminish  pressure  within  the  vascular 
system,  then  we  are  moving  on  such  lines  as  are  well  fitted  to  guide  us 
in  its  employment.  That  it  can  do. more  than  these  things  is  probable. 
That  it  does  act  as  a  derivative,  that  it  is  a  powerful  though  dangerous 
sedative,  and  that  its  employment  facilitates  the  action  of  other  remedies 
is  all  possible,  and,  although  I  believe  that  few  would  incline  to  employ 
it  for  such  ends  solely,  its  possession  of  such  potentialities  may  render  it 
of  wider  service  than  we  anticipate  when  we  use  it. 

Maybe  the  strongest  objection  to  its  employment  lies  in  the  dread  that 
by  the  abstraction  of  blood  we  tend  directly  to  weaken  our  patient ;  but 
this  fear  is,  I  am  sure,  exaggerated.  Several  observers,  among  others 
Sir  James  Paget,  believe  that  bloodletting  in  limited  quantity  is  attended 
with  little  risk  of  immediate  or  remote  injury,  and  a  physician  of  such 
eminence  and  ability  as  William  Pulteney  Alison  states  "  that  the  idea 
of  subsequent  injury  to  the  constitution  from  the  use  of  bloodletting  in 
inflammatory  diseases  may,  in  general,  be  regarded  as  quite  visionary." 
Every  obstetrician  must  have  noted  the  absolutely  unimpaired  recovery 
of  lying-in  women  in  whom  a  moderate  post-partum  hemorrhage  has 
occurred,  and  to  the  surgeon  it  is  a  matter  of  every  day  experience  that 
in  the  large  majority  of  surgical  operations  not  complicated  by  previous 
shock,  and  unattended  by  excessive  hemorrhage,  a  certain  loss  of  blood 
in  no  wise  hinders  a  satisfactory  convalescence.  In  making  such  refer- 
ences I  know  that  I  lay  myself  open  to  the  very  evident  contention,  that 
such  patients  are,  at  the  time  the  loss  is  sustained,  in  the  full  tide  of 
health,  but  this  is  hardly  so,  for  the  blood  of  the  pregnant  woman, 


MACDOUGALL,  VALUE  OF  BLOODLETTING.  39 

although  greater  in  bulk,  presents  those  very  characters  which  excessive 
hemorrhage  develops — it  is  deficient  in  hsematin,  and  it  contains  an  excess 
of  fibrin ;  while  most  surgical  patients  demanding  for  their  relief  severe 
operative  measures  cannot,  as  a  rule,  be  held  to  have  the  fullest  health. 
Moreover,  it  happens  that  in  many  cases  of  debilitating  disease,  hemor- 
rhage, it  may  be  as  the  effort  of  Nature,  does  occur,  and  its  occurrence 
hinders  neither  the  favorable  progress  of  the  malady,  nor  the  con- 
valescence from  it.  One  such  instance  occurs  to  me  now.  A  young 
gentleman,  a  patient  of  Dr.  Walker,  of  Dalston,  who  has  for  many 
years  been  the  subject  of  mitral  disease  with  well-marked  aortic  regurgi- 
tation, and  who  for  the  past  two  years  has  had  chronic  Bright's  disease, 
was  at  the  end  of  last  autumn  seized  with  acute  pleuro-pneumonia.  A 
more  unpromising  case  it  would  be  difficult  to  find,  for  he  had  suddenly 
superadded  to  his  burden  of  chronic  and  incurable  disease,  an  acute 
inflammatory  ailment,  attended  with  high  temperature,  much  dyspnoea, 
and  very  considerable  physical  suffering.  Owing,  in  part,  to  the  existence 
of  renal  disease,  and  doubtless,  in  part,  to  the  presence  of  aortic  insuffi- 
ciency, he  had  on  the  night  of  my  first  visit  a  considerable  epistaxis.  That 
it  had  done  him  no  harm  Dr.  Walker  was  confident,  and  my  own  feeling 
was  that  it  had  probably  done  him  good.  A  recurrence  happened  some 
days  later,  and,  although  upon  that  occasion,  owing  to  the  absence  of  his 
doctor,  he  lost  a  good  pint  of  blood,  which,  undoubtedly,  temporarily 
debilitated  him,  he  struggled  through  his  pneumonia,  and,  what  was 
even  more  satisfactory,  he  recovered  after  a  single  tapping  from  the 
empyema  of  which  his  pleural  effusion  was  constituted.  Had  excessive 
dyspnoea  demanded  it,  how  few  would  have  dared  to  bleed  this  man  to 
twelve  ounces,  and  yet  events  demonstrated  that  even  such  a  loss  was 
not  incompatible  with  a  satisfactory  recovery. 

It  has  been  written  by  a  great  clinician  that  "  men  bear  no  mark  that 
denotes  their  great  or  their  small  susceptibility  to  mercury,"  and  this  in 
a  measure  seems  true  of  bloodletting  also,  for  in  the  case  of  chronic  dis- 
ease I  have  related  a  very  considerable  hemorrhage  made  little  apparent 
difference,  whereas  Dr.  John  Duncan  tells  me  that  an  athletic  student 
who,  in  perfect  health,  was  bled  for  purposes  of  transfusion,  was  long  in 
recovering  from  its  effects.  That  idiosyncrasy  should  exist  with  refer- 
ence to  bloodletting,  experience  in  the  use  of  many  other  remedies  would 
lead  us  to  expect. 

In  considering  the  advisability  of  the  employment  of  bloodletting,  the 
primary  questions  which  arise  are  these :  Is  the  condition  of  the  patient 
so  urgent  as  to  demand  its  aid,  and  is  there  a  fair  probability  of  the  loss 
he  will  thus  sustain  being  satisfactorily  replaced  ?  Wise  and  necessary 
as  is  this  association  of  interests,  and  important  as  is  its  general  main- 
tenance, it  is  easy  to  understand  how  the  importunity  of  the  one  may,  at 
times,  justly  overrule  the  prudence  of  the  other,  for  when  life  is  in  im- 


40 


MACDOUGALL,  VALUE   OF  BLOODLETTING. 


minent  jeopardy  we  must  act  for  the  present,  cherishing  the  hope  that 
the  good  to  be  attained  may  quite  outdo  the  evil  attendant  upon  the 
letting  of  blood.  And  this  position  is  made  still  stronger  when  we  call 
to  remembrance  the  fact  that  in  the  very  large  majority  of  cases  the 
loss  of  blood  need  not  be  great,  for  the  effect  we  desire  is  an  immediate 
one,  one  if  at  all  attainable,  produced  very  quickly,  and,  therefore, 
bloodletting  by  possessing  this  quality  has  that  within  itself  which  is 
adverse  to  the  withdrawal  of  an  inordinate  amount.  Thus  is  it  that  the 
aphorism  of  Sir  Thomas  Watson  is  readily  compassed,  "  bleed  so  as  to 
secure  the  advantages  of  the  remedy  and  to  avoid  its  disadvantages," 
and  with  a  view  to  a  demonstration  of  the  value  it  certainly  possesses,  I 
will,  in  dealing  with  this  question,  relate  some  of  the  scattered  lessons  of 
my  own  limited  experience. 

When  bloodletting  was  in  the  plenitude  of  its  power  there  was  no 
morbid  condition  in  which  it  was  employed  more  unhesitatingly  than  in 
apoplexy.  The  reasons  for  this  are  not  difficult  to  seek,  for,  homoeopathic 
as  such  treatment  may  be  reckoned,  there  can  be  no  reasonable  doubt 
that  in  many  cases  of  severe  visceral  hemorrhage,  general  bloodletting 
is  alone  able  to  control  it.  The  temptation  to  make  this  knowledge  the 
foundation  for  action  was  doubtless  increased  by  the  condition  of  the 
pulse  generally  associated  with  cerebral  hemorrhage ;  for  the  feeling  it 
conveys  through  its  very  fulness  is  that  of  its  hurrying  on  in  such  a 
volume  as  is  certain  to  increase  extravasation  and  nerve  destruction. 
Thus;  I  fancy,  it  was  that  bloodletting  became  the  "  summum  remedium  " 
in  all  cases  of  apoplexy,  and,  although  we  now  know  that  in  the  very 
large  majority  of  instances  it  is  not  only  a  powerless,  but  a  dangerous 
remedy,  there  is  one  form  of  attack  in  which  most  physicians  agree  it 
may  still  be  employed  with  possible  benefit — that  form  is  the  ingraves- 
cent. Unhappily,  the  cases  are  rare  in  which  opportunity  offers  for  its 
use,  for  its  earlier  march,  at  times  slow  enough,  it  may  be,  to  anticipate, 
is  too  frequently  hastened  by  the  attacks  of  vomiting  which  charac- 
terize it. 

In  the  last  two  cases  that  have  come  under  my  observation  this  history 
was  most  notable,  for  with  the  access  of  vomiting  there  came  such  acute- 
ness  in  the  development  of  coma,  that  it  quite  outran  any  possible  good 
derivable  from  bloodletting. 

That  in  fitting  cases — cases  seen  early  in  their  progress — it  may  prove 
useful  I  shall  endeavor  on  lines  which  are  fairly  parallel  to  show. 

Experience  gained  by  the  surgeon  is  often  of  equal  value  to  the  phy- 
sician, for,  although  the  conditions  which  give  rise  to  certain  results 
differ,  the  results  themselves  are  so  akin  that  the  danger  pertaining  to 
them  has  a  common  significance.  Therefore  it  is  that  I  quote  the  fol- 
lowing case  to  show  that  in  bloodletting  we  have  a  remedy  of  value  in 


MACDOUGrALL,  VALUE   OF  BLOODLETTING. 


41 


"  ingravescent  apoplexy,"  albeit  that  apoplexy  be  external  to,  instead  of 
within,  the  cerebral  cortex. 

M.  B.  was  thrown  with  great  force  from  the  conveyance  in  which  he 
was  driving,  and  pitched  upon  his  head.  He  had  well-marked  concus- 
sion, followed  by  decided  reaction,  with  a  full,  but  not  too  rapid  pulse. 
Some  hours  after  he  was  first  seen  he  was  attacked  with  severe  headache, 
complained  of  a  rushing  noise  in  his  ears,  had  some  embarrassment  in 
his  breathing,  Avas  a  little  confused,  had  widely  dilated  pupils  acting 
slowly  to  light,  and  his  pulse  had  fallen  from  over  80  to  52  in  the  minute. 
He  was  at  once  bled  to  the  extent  of  a  pint,  which  relieved  his  headache, 
and  his  breathing,  and  under  which  his  pulse  rose  to  its  old  rate  of  80 
in  the  minute. 

A  few  days  after,  having,  contrary  to  all  instruction,  risen  from  his 
bed  and  made  some  exertion,  the  old  symptoms  reappeared,  headache, 
dilated  inactive  pupils,  and  slow,  laboring  pulse.  V enesection  again, 
and  with  this  great  relief,  and  an  ultimate  satisfactory  recovery. 

It  may  fairly  be  argued  that  in  this  case  I  have  no  certain  proof  to 
offer  that  extravasation  had  occurred,  and  I  am  glad  that  such  proof  is 
wanting,  but  I  have  notes  of  another  case  in  which,  following  a  severe 
blow  on  the  head,  there  were,  on  three  separate  occasions,  attacks  exactly 
similar  to  those  observed  in  M.  B.,  the  last  of  which,  unhappily,  proved 
fatal,  and  in  that  instance  a  post-mortem  examination  demonstrated  the 
presence  of  a  large  clot,  part  of  which  had  been  recently  effused,  but  of 
which  other  portions  had,  undoubtedly,  been  in  existence  for  some  little 
time.  I  record  it  as  a  matter  of  regret,  that  this  case  was  not  treated  by 
venesection.  It  seems  then  but  a  fair  deduction  that  a  remedy  which 
can  arrest  hemorrhage  occurring  outside  the  brain,  should  have  equal 
power  to  control  leakage  taking  place  in  its  substance. 

The  power  for  good  possessed  by  bloodletting  in  morbid  states  of  the 
cerebral  circulation  is  not,  however,  confined  to  the  arresting  of  hemor- 
rhage. There  are  certain  pathological  conditions  attended  by  convulsive 
phenomena  over  which  it  exercises  a  happy  control.  The  rationale  of 
this  is  readily  found  through  a  mechanical  explanation,  for  the  tightly 
packed,  and  the  unyielding  character  of  the  cerebral  case,  renders  any 
disturbance  in  its  vascular  system  fraught  with  very  decided  danger.  If 
the  amount  of  blood  circulating  in  it  be  of  necessity  an  ever  definite 
quantity — -and  this,  I  believe,  has  been  fairly  demonstrated — then  it 
follows  that  disturbance,  say  of  a  spasmodic  character,  in  the  arterial 
system  must  be  associated  with  a  plethora  on  the  venous  side.  By  their 
researches,  Kussmaul  and  Tenner  proved  that  sudden  cerebral  anaemia 
may  induce  convulsion,  and  there  is  a  strong  probability  that  the 
"status  epilepticus,"  when  fully  developed,  depends  upon  a  pronounced 
ansemia  in  certain  cerebral  areas.  This  was  the  contention  of  Sir  J.  C. 
Brown,  and  the  basis  upon  which  he  founded  his  treatment  of  it  by  the 
use  of  nitrite  of  amyl.    Before,  however,  this  valuable  remedy  had 


42 


MACDOUG-ALL,  VALUE   OF  BLOODLETTING. 


been  used  in  this  way,  it  had  happened  to  me  to  find  how  completely 
this  dangerous  condition  could  be  relieved  by  free  venesection. 

One  case  I  well  remember,  where  the  fits  recurred  with  such  rapidity 
and  regularity,  and  where  the  intervals  were  marked  by  so  profound  a 
state  of  coma,  that  the  man's  condition  seemed  well  nigh  hopeless.  A 
big  bleeding,  for  he  was  a  strong,  healthy  man,  at  once  arrested  his  fits 
and,  I  believe,  saved  his  life.  That  it  acted  by  relieving  a  stasis  in  the 
cerebral  venous  system,  and  thus  permitted  a  readier  transmission  of 
blood  through  the  smaller  arteries  and  capillaries,  is  probable. 

Trousseau  draws  attention,  in  one  of  his  masterly  lectures,  to  the  fact 
that  in  certain  cases  of  convulsive  epilepsy  we  may  have  a  state  of  tonic 
convulsions  lasting  for  a  long  time,  "  two  or  three  minutes,  instead  of 
three  times  the  number  of  seconds,  and  death  from  asphyxia  as  a  con- 
sequence." I  once  witnessed  in  a  little  girl,  the  subject,  not  of  true 
epilepsy,  but  of  most  severe  convulsions  depending  upon  a  functional 
cause,  this  very  state  established,  and  the  happy  issue  that  resulted  from 
the  abstraction  by  me  of  a  few  ounces  of  blood  from  the  external  jugular, 
was  one  of  the  early  experiences  of  my  professional  life. 

If  the  theory  of  Dr.  Hughlings  Jackson  {Brain,  April,  1886)  be  cor- 
rect, that  infantile  convulsions  depend  largely  for  their  development 
upon  a  venous  condition  of  the  blood  circulating  in  the  respiratory 
centre,  then  it  is  not  difficult  to  understand  how  oft-repeated  and  long- 
continued  spasm,  interfering  as  it  does  with  the  respiratory  act,  should 
perpetuate  the  tumult,  and  how  direct  relief  to  the  venous  system  may 
speedily  arrest  the  convulsive  disturbance. 

Before  proceeding  to  allude  to  those  conditions  in  which  the  benefit 
attending  bloodletting  is  conspicuous  and  undoubted,  I  would  make 
mention  of  the  advantage  which  attends  its  employment  in  certain  cases 
of  simple  croup.  I  am  not  likely  now  ever  to  forget — for  the  early 
writings  on  the  folds  of  memory  are  the  most  indelible — the  relief  which 
I,  when  a  little  lad,  suffering  from  croup,  obtained  by  venesection. 
Emetics,  hot  fomentations,  and  the  warm  bath,  had  all  been  employed, 
but  with  no  benefit,  the  dreadful  feeling  of  suffocation  was  still  unre- 
lieved, while  following  immediately  the  withdrawal  of  several  ounces  of 
blood  from  the  arm  I  was  easy  and  comfortable. 

It  would  be  a  marvel,  then,  that  if  thus  taught,  it  seemed  the  lesson 
of  a  life  in  its  fullest  sense,  I  should  have  denied  the  same  relief  to 
others,  and  thus  it  is  that,  in  late  childhood  and  early  youth,  when 
other  means  have  failed,  and  when  in  vigorous  adolescents,  cynanche 
laryngea  is  marked  by  the  symptoms  noted  by  Cullen,  "  respiratio  diffi- 
cilis,  inspiratio  strephens,  vox  rauca,  tussis  clangosa,"  then  my  trust,  and 
my  expectation,  lie  in  a  moderate  phlebotomy. 

In  the  treatment  of  visceral  inflammations  bloodletting  held  for  long 
the  leading  place,  and  although  the  virtues  it  was  said  to  possess  are  by 


3IACD0UGALL,  VALUE   OF  BLOODLETTING. 


43 


many  openly  questioned  to-day,  there  undoubtedly  exist  still  certain 
conditions,  the  result  of  inflammatory  hyperemia,  where  its  action  is  of 
signal  benefit.  That  this  should  be  so  seems  a  natural  inference  when 
we  recall  the  fact  that  in  disturbed  and  perverted  action  of  the  vascular 
system,  arise  those  changes  which  mark  this  morbid  state,  and  that 
bloodletting  exercises  such  power  over  the  circulation  as  is  unmistak- 
able and  undeniable.  That  the  establishment  of  acute  hyperemia  in 
the  pulmonary  area  should  exert  a  most  pronounced  effect  on  the  whole 
vascular  system,  and  that  the  action  of  bloodletting  should,  in  this  case, 
may  be,  best  demonstrate  its  power  is  readily  surmised. 

The  further  fact,  that  the  manifestation  of  this  power  is  immediate 
renders  it  in  such  conditions  as  those  to  which  reference  will  be  made, 
of  the  very  highest  value.  The  little  knowledge  I  have  of  its  employ- 
ment in  pneumonia  is  in  no  wise  sufficient  to  justify  any  expression  of 
opinion  as  to  its  favorable  effect  upon  the  type,  and  the  duration  of 
inflammatory  disease.  All  I  wish  to  claim  for  it  is  its  mechanical  power 
of  relieving  suffering,  of  relieving  blood-stasis,  of  restoring  a  lost  balance 
between  heart  and  arteries,  and  in  this  wise  abating  certain  symptoms, 
the  presence  of  which  threaten  very  directly  the  life  of  the  patient. 

In  pleurisy  attended  with  grave  inflammatory  fever,  with  severe 
stitch,  and  with  much  difficulty  in  breathing,  I  have  seen  the  most 
marked  relief  follow  the  practice  of  bloodletting.  [Now,  however,  that 
we  possess  in  the  hypodermatic  injection  of  morphia  so  direct  and  so 
speedy  a  means  of  allaying  pain,  the  temptation  to  use  the  lancet  is  not 
so  great,  for  if  there  was  one  feature  in  the  case  which  venesection  did 
benefit,  it  was  the  intolerable  suffering  the  patient  was  enduring. 

I  have  a  belief  that  the  most  dangerous  forms  of  this  disease  are  not 
those  in  which  there  is  much  effusion,  rather  are  they  marked  by  the 
exudation  of  lymph  over  a  very  wide  area,  and  it  was  in  the  early 
days  of  such  cases  that  venesection  seemed  to  me  to  prove  most  bene- 
ficial. 

Around  the  treatment  of  pneumonia  has  the  dispute  regarding  the 
virtues  and  the  evils  of  bloodletting  raged  most  fiercely..  This,  to  say 
the  least  of  it,  has  been  unfortunate,  for,  although  there  can  be  no 
doubt  that  indiscriminate  bloodletting  in  pneumonia  did  an  infinitude  of 
harm,  and  ought,  as  a  rule,  to  be  entirely  deprecated,  there  is  still  one 
form  of  the  disease,  and .  there  are  certain  states  which  may  arise  in  its 
ordinary  course,  in  which  to  withhold  its  performance  would  be  a  grave 
error. 

Let  me,  by  the  short  narration  of  a  case,  illustrate  the  form  of 
pneumonia  in  which,  by  its  action,  it  may  prove  more  than  a  mere 
alleviator. 

A.  H.,  a  strong,  muscular  ploughman,  had,  by  an  unfortunate  accident, 
the  wheel  of  a  heavily  loaded  cart  "  backed  "  across  the  right  side  of  his 


MACDOUGALL,  VALUE   OF  BLOODLETTING. 


chest.  Five  at  least  of  his  ribs  were  fractured;  he  had  considerable 
emphysema,  some  pneumothorax,  and  pretty  profuse  haemoptysis. 
Thirty -six  hours  after  the  receipt  of  his  injury  he  was  found  with  all 
the  symptoms  of  acute  pneumonia.  He  had  grave  inflammatory  fever, 
his  temperature  was  high,  his  pulse  hard  and  full,  he  had  an  incessant 
short  cough,  and  much  difficulty  in  his  respiration.  That  this  difficulty 
was  in  a  measure  brought  about  by  the  pain  attending  upon  the  in- 
creased respiratory  efforts  was  very  apparent. 

It  was  impossible  to  examine  satisfactorily  the  anterior  part  of  the 
chest,  but  behind,  he  had  over  a  wide  area  very  decided  dulness  upon 
percussion,  with  harsh  respiration.  I  bled  him  freely  from  the  arm, 
with  great  and  immediate  relief.  Within  the  next  twenty-four  hours 
his  pulse  and  temperature  fell  quickly,  and  although  his  lung  afforded 
evidence  of  more  or  less  consolidation  for  some  days  after,  it  never,  I 
believe,  reached  the  stage  of  true  hepatization. 

That  in  this  case  bloodletting,  by  the  power  it  exercised  over  the 
distribution  of  blood,  carried  relief  to  the  pulmonary  circulation,  which, 
through  the  operation  of  various  factors  had  become  overcharged,  and 
thus  assuaged  dangerous  symptoms,  is  fairly  certain. 

Wide,  and  great,  as  the  difference  undoubtedly  is  between  pneumonia 
following  an  injury,  and  the  disease  as  we  meet  it  in  the  ordinary  way, 
and  certain  as  is  the  tendency  it  often  has,  when  appearing  in  this  shape, 
to  terminate  life  by  asthenia,  we  may  witness  ever  and  again  in  its 
course  such  conditions  as  demand  for  their  relief  that  promptitude  in 
action  which  bloodletting  alone  can  bring,  and  here  again  I  will  make 
use  of  a  clinical  note. 

B.  G.,  a  healthy  lad  of  twenty,  was  the  subject  of  right-sided  pneu- 
monia. For  the  first  five  days  of  his  illness  matters  went  fairly  well 
with  him.  He  had  a  quick  pulse,  and  a  high  temperature,  but  his 
respiration  was  not  more  rapid,  or  more  distressing,  than  the  pretty 
complete  involvement  of  nearly  his  whole  right  lung  readily  explained. 

On  the  sixth  morning,  however,  the  aspect  had  changed — he  was 
struggling  for  breath,  his  face,  his  lips,  and  his  tongue  were  livid,  his 
pulse  was  quick  and  small,  but  he  had  a  strongly  beating  heart  and  copious 
pneumonic  expectoration.  Examination  of  the  back  of  his  chest  revealed 
the  fact,  that  in  addition  to  the  harm  in  his  right  side,  he  had  now  fine 
crepitation  over  the  left  base,  proving  that  both  lungs  were  implicated. 
He  was  at  once  bled  to  ten  ounces  and  with  immediate  relief.  Stimu- 
lants and  liquid  nourishment  were  given  him  with  a  free  hand,  his  poul- 
tices were  continued,  and  he  ultimately  made  an  excellent  recovery. 

The  explanation  of  the  sudden  gravity  of  this  man's  condition  lay  in 
the  occurrence  of  over-distention  of  the  right  heart,  the  direct  sequence 
of  that  further  obstruction  in  the  pulmonary  circulation  which  the  con- 
gestion of  the  left  lung  had  brought  about.  The  feebleness  of  his  pulse 
at  the  wrist,  proof  of  the  small  quantity  of  blood  pouring  into  the  left 
ventricle,  and  the  violently  acting  heart  excited  by  the  presence  of  an 
unwonted  amount  of  blood,  and  doing  that  which  in  it  lay  to  overcome 


MAC  DOUG  ALL,  VALUE  OF  BLOODLETTING.  45 

an  obstruction  which  threatened  the  extinction  of  its  action,  formed  the 
best  and  the  surest  indication  for  the  abstraction  of  blood.  Vigorous  as 
a  heart  may  be,  and  capable  in  ordinary  circumstances  of  contending 
for  a  time  with  stasis  in  the  pulmonary  circuit,  there  can  be  no  doubt 
that  in  the  pyrexia  which  marks  the  pneumonic  process,  we  have  that 
which,  by  favoring  the  occurrence  of  rapid  dilatation,  renders  the  struggle 
more  doubtful,  and  the  necessity  for  immediate  action  more  imperative. 
For  this  reason  it  is  that  in  extreme  dyspnoea,  and  when  there  is  evi- 
dence of  a  lost  balance  between  the  right  and  left  heart,  a  remedy  which 
like  bloodletting  is  proximate  in  its  action,  is  of  the  very  highest  value. 

Prevalent  as  is  pneumonia,  and  frequent  as  are  the  opportunities 
afforded  to  the  practitioner  for  observation  of  its  treatment,  the  occa- 
sions are  very  few,  and  very  far  between,  in  which  bloodletting  is 
demanded. 

It  is,  however,  otherwise  with  another  disease  of  the  lungs — acute 
pulmonary  oedema — suffocative  catarrh. 

I  am  not  aware  that  the  essential  pathology  of  this  condition  is  fully 
determined.  It  is  often  so  sudden  and  so  swift  in  its  onset,  so  evanes- 
cent in  its  existence,  attended  by  so  little  constitutional  disturbance,  and 
withal  so  grave  in  its  possible  results,  that  it  may  well  be  a  neurosis— 
vasomotor  in  its  seat,  and  having  for  its  characteristic  feature  the  rapid 
outpouring  of  mucus  into  the  smaller  bronchi.  It  very  usually  arises 
from  exposure  to  cold  during  the  existence  of  a  bronchial  catarrh,  and 
it  is  strongly  predisposed  to  by  the  presence  of  disease  of  either  the  heart 
or  kidney.  In  both  these  morbid  states  there  doubtless  exist  such 
vascular  conditions  as  influence  gravely  the  mechanism  of  the  pulmo- 
nary circulation,  and  dependent,  mayhap,  upon  this  fact  rests  the  value 
of  bloodletting  in  its  treatment. 

How  great  that  may  be,  this  case  will  best  explain. 

A  gentleman,  past  middle  life,  consulted  me  some  time  ago  on  account 
of  dyspnoea  on  exertion.  He  had  been  quite  well  until  a  few  months 
before  he  visited  me,  when,  without  warning  of  any  kind,  he  had  an 
attack  of  pulmonary  apoplexy  which  nearly  proved  fatal.  His  pulse 
struck  me  as  hard  and  tense,  and  his  heart-action  as  too  forcible, 
although  there  was  no  very  decided  increase  in  the  cardiac  dulness. 
There  was,  however,  a  marked  impurity  and  prolongation  of  the  first 
sound  at  the  apex,  and  a  certain  heaving  action  in  this  situation.  The 
second  sound  at  the  base  was  markedly  accentuated. 

I  examined  his  urine  with  care — it  was  of  acid  reaction,  of  good 
specific  gravity  (1.025),  and  was  free  from  albumen. 

I  was  puzzled,  for  I  expected  to  find  evidence  of  a  granular  kidney, 
and  failing  in  this  I  fell  back  upon  the  hypothesis  that  he  might  possibly 
have  slight  mitral  stenosis. 

Uncertain  on  this  point,  and  still  believing  that  arterial  tension  wms 
playing  a  part  in  the  production  of  his  symptoms,  small  doses  of  calomel 
were  prescribed,  and  he  was  carefully  dieted.    From  time  to  time  lie 


46  M  AC  DO  U  G  ALL,  VALUE   OF  BLOODLETTING. 


called  upon  me,  and  his  record  was  one  of  improvement.  Then  at  mid- 
night on  the  16th  of  October  I  was  sent  for  hurriedly,  and  found  him 
extremely  ill.  He  had  caught  cold  a  week  before,  and  had  had  more 
or  less  cough.  On  the  afternoon  of  his  attack — a  cold,  raw  day — he  had 
driven  many  miles  in  an  open  carriage.  Up  to  the  time  of  his  retiring 
to  rest  he  made  no  complaint,  but  as  sleep  was  about  to  overtake  him, 
he  was  suddenly  roused  by  a  feeling  of  intense  dyspnoea.  Living  as  he 
does  close  by  me,  I  was  soon  beside  him.  He  was  propped  up  in  bed, 
and  wheezing  loudly ;  his  face  was  flushed,  his  expression  anxious,  and 
while  he  breathed  with  great  difficulty,  he  expectorated  from  time  to 
time  the  reddish  mucus  characteristic  of  suffocative  catarrh.  His 
pulse  of  80  was  hard  and  laboring,  but  his  heart's  action  was  not  per- 
ceptibly increased,  either  in  rapidity  or  in  force,  and  his  chest,  clear  on 
percussion,  was  filled  with  mucous  and  submucous  rales,  with  an  entire 
absence  of  vesicular  murmur.  Short  time  as  the  attack  had  lasted  his 
condition  was  too  grave  to  be  benefited  by  the  use  of  expectorants,  and 
I  made  preparation  to  give  him  a  subcutaneous  injection  of  apomorphia. 
The  advance  of  the  disease  was  more  rapid  than  my  action,  and  he 
quickly  passed  into  that  state  of  semi-consciousness  when  the  action  of 
emetics  is  neither  so  prompt  nor  so  satisfactory. 

Dr.  Lockie,  for  whom  I  had  sent,  now  joined  me,  and  we  happily 
agreed  as  to  the  employment  of  bloodletting  ;  he  however  remarked,  and 
I  quote  his  words  to  mark  the  gravity  of  the  case,  "  bleed  him  or  not  he 
will  die."  He  was  now  more  or  less  unconscious,  he  was  livid  in  color, 
and  his  heart,  quickening  in  action,  was  unquestionably  failing  in  power. 

The  opening  of  a  vein  in  the  left  arm,  performed  in  the  usual  way, 
proved  futile,  for  the  blood  was  so  thick  and  tarry  that  it  would  not 
flow  from  it ;  so  dissecting  down  upon  the  right  median  basilic,  and 
exposing  its  surface  clearly,  I  made  into  it  a  long  and  free  incision.  By 
constant  pressure  and  friction  the  stream  began,  slow  at  first,  and  then 
more  full,  and  when  a  pint  of  blood  had  escaped  he  expressed  himself 
as  "  beginning  to  be  relieved."  Another  pint  was  taken,  and  as  the  arm 
was  being  bound  up,  he  said,  "  I  am  quite  well ;  I  could  rise  and  walk." 
Within  thirty-six  hours,  and  without  the  occurrence  of  much  expectora- 
tion, all  rales  had  disappeared  from  his  chest,  and  he  was  in  his  usual 
health.  Since  then  he  has  had  another  similar  attack,  not  attended, 
however,  with  quite  such  peril,  for  he  was  seen  early,  and  he  was  bled 
to  twelve  ounces.  The  relief  obtained  upon  this  occasion  was  as  striking 
as  it  was  upon  the  previous  one. 

Now,  his  case  is  clear,  there  is  a  trace  of  albumen  in  the  urine,  there 
are  to  be  found  a  few  granular  casts,  and  he  presents  unmistakable 
evidence  of  considerable  arterial  tension. 

In  cases  such  as  this,  where  the  advance  of  disease  outstrips  the  action 
of  all  ordinary  remedies,  the  immediate  effect  of  bloodletting  touches 
the  miraculous. 

To  the  good  it  can  accomplish  in  cases  of  mitral  stenosis,  when,  under 
certain  circumstances,  the  chronic  condition  of  distention  of  the  right 
ventricle,  always  more  or  less  in  existence,  becomes  suddenly  aggra- 
vated, I  can  bear  no  personal  testimony ;  but  the  want  of  it  is  of  small 
moment  when  I  can  refer  for  confirmation  to  the  writings  of  Broadbent, 
of  Chambers,  and  of  many  other  able  physicians. 


MACDOUGALL,  VALUE   OF  BLOODLETTING. 


47 


Here,  however,  I  would  add  an  interrogatory  note. 

It  is  well  known  how  much  Dr.  Angus  Macdonald  ("  Heart  Disease 
during  Pregnancy  ")  did  to  bring  into  recognition  the  peculiar  dangers 
attendant  upon  cardiac  disease  in  childbearing  women,  and  how  valu- 
able are  his  records  of  the  unfortunate  progress  of  some  of  these  cases. 
In  one  such,  not  however  under  my  own  care,  in  which  mitral  disease 
and  pulmonary  oedema  brought  about  a  condition  of  extreme  gravity 
during  labor,  venesection  proved  of  the  greatest  benefit,  and  I  have  a 
belief  that  I  have  seen  relief  to  the  struggling  action  of  the  diseased 
heart  brought  about  by  the  increased  tension  accompanying  delivery, 
follow  the  occurrence  of  a  somewhat  free  post-partum  hemorrhage.  It 
is  quite  possible,  then,  that  venesection  might  relieve  the  serious  symp- 
toms which,  in  such  circumstances,  at  times  immediately  follow  delivery. 

Among  the  new  phrases  which  mark  the  advance  of  the  science  of 
medicine  there  is  none  better  known  than  that  of  "arterial  tension," 
yet  some  accept  its  existence  with  reservation,  and  incline  to  believe, 
that  as  its  presence  is  not  easily  refuted,  and  is  often  more  a  matter  of 
opinion  than  demonstration,  it  is  a  modern  term  apt  to  be  used  with  too 
convenient  a  looseness.  It  seems  to  me,  however,  that  in  the  recognition 
of  that  hard,  incompressible  character  of  the  pulse,  which  formerly  led 
so  often  to  the  practice  of  venesection,  lies  the  demonstration,  that 
although  lacking  that  full  knowledge  of  the  dangers  which,  to  us,  this 
condition  portends,  arterial  tension  has  long  been  regarded  by  the  pro- 
fession as  one  of  the  states  which  bloodletting  can  successfully  combat. 
And  so  it  remains,  for,  spite  of  the  teaching  of  Foster,  that  moderate 
bloodletting  does  not  reduce  blood-pressure,  there  is  ample  clinical  evi- 
dence to  show  that  it  possesses  the  power  of  relieving  those  urgent  symp- 
toms which  are  the  direct  issue  of  acute  increase  in  vascular  tension. 

High  arterial  tension  is  most  familiar  to  us  in  connection  with  renal 
disease,  and  some  of  the  most  formidable  states  which  arise  in  its  course 
have  probably  a  very  close  connection  with  its  existence. 

The  pulse  in  some  cases  of  acute  Bright's,  and  in  granular  disease  of 
the  kidney  generally,  has  very  special  characteristics,  and  when,  as  time 
runs  and  under  the  retarding  action  of  the  muscular  arterioles  pressure 
in  the  arteries  rises  high,  its  cord-like  feeling  in  unmistakable.  Then  it 
is,  I  believe,  that  convulsive  phenomena  are  most  apt  to  make  their 
appearance,  and  in  certain  cases  imperatively  demand  for  their  relief  the 
employment  of  general  bloodletting. 

How  valuable  this  may  prove,  the  following  case,  the  last  of  its  kind 
which  has  come  under  my  observation,  and  belonging  to  a  group  well 
known  to  most  practitioners,  albeit  the  subjects  are  generally  of  more 
tender  years,  will  show. 

Some  little  time  ago  I  saw  with  a  practitioner  in  a  neighboring  county, 
a  gentleman  suffering  from  scarlatinal  nephritis.    He  had  been  ill  for 


48 


MACDOUGALL,  VALUE   OF  BLOODLETTING. 


three  days  when  I  was  asked  to  visit  him,  and  he  had  been  treated  in 
the  most  judicious  way.  He  had  been  purged,  had  hot  air  baths,  had 
pilocarpine  injections,  and  such  a  diet  as  was  best  suited  for  him.  Still 
he  did  not  improve,  his  urine  was  exceedingly  scanty  and  highly  albu- 
minous and  a  complaint  of  some  dimness  in  vision  made  his  attendant 
anxious  about  him.  At  the  time  we  entered  his  room  together  he  was  in 
a  violent  convulsion,  a  foreboding  of  which  occurred  about  an  hour  pre- 
viously when  he  became  suddenly  quite  blind.  When  the  violence  of 
the  seizure  had  passed  he  was  deeply  unconscious,  pale  in  the  face,  with 
a  small  pulse  at  the  wrist,  hard,  however,  and  unyielding  as  whipcord, 
and  with  a  forcibly  acting  heart,  of  which  the  sounds,  both  at  base  and 
apex  were  highly  accentuated.  With  the  acquiescence  of  his  doctor  I 
bled  him  freely  from  the  arm,  and  with  such  benefit  that  in  a  little  while 
he  became  conscious  and  made  complaint  of  headache.  Two  hours  after 
we  left  him  he  had  another  but  much  milder  fit,  in  the  struggles  of  which 
the  retaining  bandage  on  the  arm  became  undone  and  he  sustained  a 
further  loss  of  blood.  This,  however,  did  him  no  harm,  for  when  his 
attendant,  sent  for  hurriedly  to  visit  him,  arrived,  he  found  him  fully 
conscious  and  free  from  discomfort.  This  condition  happily  proved  per- 
manent, there  was  no  recurrence  of  the  convulsion,  and  he  made,  thanks 
largely  to  the  bloodletting,  an  unusually  rapid  and  satisfactory  recovery. 

A  case  of  renal  disease  such  as  this,  is  typically  the  one  in  which 
bloodletting  may  be  employed  without  hesitation.  The  condition  which 
has  led  to  the  production  of  the  convulsion  is  acute  in  character,  it  has 
been  but  a  short  time  in  existence,  there  is  no  preexisting  impoverish- 
ment of  the  blood,  and  nothing  of  that  deep  undermining  of  the  strength 
which  marks  the  chronic  Bright's.  Apart  altogether  from  the  unmistak- 
able relief  to  the  convulsive  disturbance  which  venesection  in  such  cir- 
cumstances usually  brings,  there  is  the  further  possible  good  it  confers 
upon  the  general  state  of  the  patient.  It  is  not  often  that  now  Ave  treat 
inflammation  as  such  by  the  abstraction  of  blood,  and  yet  I  venture  to 
believe  that  in  acute  nephritis,  occurring  in  a  robust  and  healthy  subject, 
there  is  no  line  of  primary  treatment  more  likely  to  prove  beneficial 
than  venesection.  My  reasons  for  thinking  this  are  twofold :  one  the 
knowledge  that  in  some  instances  death  has  been  the  direct  and  rapid 
result  of  such  cardiac  harm  as  is  brought  about  by  the  sudden  occur- 
rence of  acute  arterial  tension ;  and  the  other,  the  observation,  frequently 
repeated,  of  the  immense  benefit  which  has  followed  the  occurrence  of  a 
smart  attack  of  hematuria.  There  is  probably  no  organ  in  the  body  in 
which  vascular  pressure  is  so  consistently  high  as  in  the  kidney,  and 
none  in  which  bloodletting  has  more  decided  effect,  as  witness  the  benefit 
which  follows  its  practice  in  certain  cases  of  severe  renal  hemorrhage. 

In  dealing  with  convulsions  in  cases  of  chronic  diseases  of  the  kidney 
in  some  of  whioh  it  is  of  striking  value,  we  require  to  be  more  guarded 
in  its  employment.  Here  two  points  are  worth  remembering.  The  one, 
especially  applicable  to  such  cases,  is  the  dictum  of  Graves  in  connection 
with  bleeding,  that  <;  you  may  rely  on  it  that  every  ounce  of  healthy 


MACDOUG-ALL,  VALUE   OF  BLOODLETTING. 


49 


blood  you  take  away  is  shortly  replaced  by  two  ounces  very  inferior  in 
quality,"  and  the  other,  that  an  impoverished  condition  of  the  blood  is  a 
factor  in  the  production  of  ursemic  convulsion,  and  that  bloodletting  by 
producing  this  state  may  predispose  to  future  attacks.  In  some  patients, 
however,  enfeebled  beyond  all  doubt,  in  whom  convulsions  have  their 
origin  in  local  cerebral  oedema,  its  occurrence  marked,  it  may  be,  in 
addition  by  the  presence  of  hemiplegia,  a  small  bleeding  of  one  ounce  or 
two  may  prove  of  the  greatest  benefit.  It  is  no  doubt  difficult  in  some 
instances  to  diagnosticate  the  morbidness  which  underlies  the  state  of 
the  patient  from  that  of  cerebral  hemorrhage,  but  where  convulsions 
are  recurring,  and  the  temperature  is  subnormal,  it  is  wisest  to  let  blood. 

In  very  intimate — in  almost  inseparable — relation  with  the  convul- 
sions to  which  I  have  referred,  are  those  observed  in  the  pregnant  and 
parturient  woman.  It  has  sometimes  occurred  to  me  that  the  bond  of 
relationship  which  binds  them  most  closely  to  one  another,  is  that  of 
high  arterial  tension.  I  have  witnessed  most  severe  eclampsia  in  a  case 
in  which  there  was  comparatively  little  albuminuria,  and  if  we  estimate 
— and  I  believe  that  in  such  cases  it  is  a  pretty  reliable  guide — the 
extent  of  damage  to  the  kidney  by  the  amount  of  albumen  thrown 
down,  then  we  must  look  for  something  besides  the  renal  mischief  to 
account  for  the  production  of  convulsions. 

This,  I  take  it,  will  be  found  in  that  normally  existing  state  of  pro- 
nounced arterial  tension  which  is  the  constant  accompaniment  of  gesta- 
tion. The  presence  of  cardiac  hypertrophy,  increase  in  renal  pressure, 
increase  in  the  quantity  of  blood,  and  probable  increase,  as  mooted  by 
Barnes,  in  nervous  force,  all  contribute  to  the  production  of  increase  in 
vascular  pressure,  and  when,  superadded  to  these  many  separate  factors, 
we  have  nephritis — probably  degenerative  in  its  nature — bringing  as  its 
results  not  only  a  further  and  harmful  increase  in  the  quantity  of  blood 
in  the  vessels,  but  most  marked  deterioration  in  its  quality,  then  it  is 
readily  understood  how  a  minor  degree  of  renal  mischief  may  determine 
the  occurrence  of  eclampsia. 

The  best  known  theories  regarding  the  causation  of  puerperal  convul- 
sions have  for  their  basis  this  excess  in  arterial  tension,  and  therefore  it 
might  seem  a  priori  that  in  such  cases  bloodletting  would  prove  useful. 
And  so  it  does  in  some,  for  although  in  the  majority  the  use  of  chloro- 
form, chloral,  or  pilocarpine,  remedies  possessing  the  power  directly  or 
indirectly  of  lowering  vascular  tension,  may  be  found  sufficient,  there 
yet  exists  a  minority  of  cases,  in  which  the  form  and  the  gravity  of  the 
seizure  demand  for  its  safest  treatment  recourse  to  venesection. 

Marked  severity  of  attack,  with  extreme  congestion  of  the  nice,  and 
turgidity  of  the  vessels,  as  its  characteristics;  and  profound  coma,  with 
flushed  face,  and  a  hard,  long  pulse,  in  the  intervals  of  the  seizure^ 
form,  maybe,  the  most  reliable  guides  for  such  treatment.    I  well  rc- 

NO.  CLXXXVII.— JULY,  1887.  4 


50 


MACDOUGALL,  VALUE    OF  BLOODLETTING. 


member  one  such  case,  a  primipara  seized  within  an  hour  of  her  delivery 
with  convulsions  of  such  frightful  severity  as  to  render  their  remem- 
brance with  me  indelible,  and  how,  after  chloroform  had  been  used 
without  avail,  a  free  venesection  altered  at  once  the  whole  aspect  of  her 
condition.  I  am  happy  in  this  experience,  that  although  all  the  cases 
I  have  seen  were  not  treated  by  bloodletting,  those  which  were,  and 
these  the  most  severe,  made  excellent  recoveries,  and  whether  due  to 
the  fact  that  such  treatment  tended  to  the  more  speedy  cure  of  the 
kidney  disease,  or  that  they  lacked  a  vital  tendency  to  its  development, 
they  all  escaped  what  unhappily  came  to  some  of  the  others,  recurrent 
puerperal  nephritis,  with  its  sad  tale  of  disaster. 

The  importance  attaching  to  the  condition  of  high  arterial  tension 
becomes  increased  by  the  knowledge  of  the  fact  that  it  may  exist  inde- 
pendently of  disease  of  the  kidney,  and  that  it  may  prove  the  cause  of 
such  convulsive  phenomena  as  are  indistinguishable  in  their  characters 
from  those  that  mark  urasmia.  That  this  depends  upon  the  peculiarities 
of  the  cerebral  circulation  is  most  probable.  It  is  not  easy,  as  Broad- 
bent  has  pointed  out,1  to  say  how  convulsions  are  produced,  but  if  we 
admit  that  acute  increase  in  vascular  tension  has  a  possible  power  of 
causing  anamiia  of  the  brain  with,  perchance  for  its  sequence,  a  serous 
effusion  in  the  meninges,  and  that  it  may  give  rise  to  the  occurrence  of 
capillary  hemorrhage  in  its  substance,  then  we  can  understand  how 
capable  it  may  prove  of  producing  such  nerve  storms  as  betoken  the 
occurrence  of  some  hitch  in  the  circulatory  balance  of  the  great  seat  of 
nervous  force.  The  harm  to  which  it  gives  rise  is,  however,  not  always 
so  startlingly  evident,  but  it  is  none  the  less  grave;  cardiac  disease,  aneu- 
rism, arterial  degeneration,  these  all  follow  in  its  train,  and  render  it 
one  of  the  conditions  in  which  a  ready  recognition  and  a  fitting  treat- 
ment must  go  hand  in  hand.  It  has  happened  to  me  on  several  occasions 
to  observe  in  elderly  men,  the  subjects  of  gout,  how  much  relief  has 
been  brought  to  somewhat  indefinite  but  most  troublesome  symptoms  by 
a  smart  epistaxis. 

Last  autumn  I  had  under  my  care  a  gentleman  of  sixty,  of  well- 
marked  gouty  tendency,  suffering  from  headache,  giddiness,  and  extreme 
irritability  of  temper.  He  had  all  the  physical  signs  of  high  arterial 
tension,  but  without  evidence  of  any  organic  disease.  He  was  treated 
by  calomel  and  salines  as  active  purgatives,  and  he  was  carefully  dieted, 
but  with  little  improvement,  until  the  occurrence  of  a  severe  epistaxis 
brought  him  entire  relief.  Then  I  recognized  fully  how  certainly  a 
moderate  bloodletting  would  have  saved  him  suffering,  and  myself 
anxiety  concerning  him. 

His  was  one  of  the  cases  in  which  there  is  no  existing  disease  of  the 


l  Lancet,  1883,  vol.  i.  p.  4  et  seq. 


MACDOUGALL,  VALUE   OF  BLOODLETTING. 


51 


kidney,  but  in  which  a  gouty  condition  of  the  blood,  coupled  maybe 
With  a  plethora,  led  to  increase  in  arterial  tension,  and,  as  sometimes 
happens,  to  apoplexy  as  an  unhappy  sequel. 

The  term  of  gestation  is  not  the  only  period  in  a  woman's  life  when 
she  may  become  the  subject  of  high  arterial  tension.  It  may  come  to 
her  in  the  earlier  years  which  succeed  the  establishment  of  menstruation, 
through  continued  amenorrhcea,  and  it  may,  and  very  frequently  does, 
during  the  epoch  of  the  climacteric.  Many  of  the  very  trying  subjective 
symptoms  of  which  bitter  complaint  is  made  at  this  especial  time  have 
their  origin  in  vascular  disturbance,  and  I  have  noted  in  some  cases  how 
relief  to  them  most  certainly  followed  the  action  of  such  remedies  as 
render  the  pulse  softer  and  more  full.  But  its  ill  effects  may  be  so 
pronounced  as  to  endanger  life.  Here  is  an  instance,  the  most  pro- 
nounced I  have  ever  seen,  but  fraught  with  instruction : 

In  the  early  hours  of  a  morning  in  last  June  I  received  a  note  from 
Dr.  Graham,  of  Kirklinton,  asking  me  to  see  with  him  a  patient  who 
was  thought  to  have  had  an  apoplectic  attack.  She  was  a  farmer's  wife 
of  forty-five,  stout,  red-faced,  and  plethoric.  For  nearly  four  months 
the  catamenia,  normally  large  in  amount,  had  disappeared,  and  latterly 
she  had  been  short-winded  and  her  respiration  very  easily  distressed. 
Her  doctor  had  seen  her  on  several  occasions,  because  she  had  general 
malaise  and  headache,  but  there  seemed  nothing  in  her  state  to  provoke 
anxiety.  On  the  evening  preceding  my  visit  he  had  called,  and  found 
her  much  in  her  usual  state,  except  that  a  slight  menstrual  discharge 
had  made  its  appearance.  At  midnight  she  was  discovered  to  be  in  a 
condition  of  profound  coma,  and  in  this  state  Dr.  Graham  found  her. 
When  we  met  at  her  bedside  she  was  better,  for  she  could  be  roused 
sufficiently  to  answer  questions,  but  she  was  stupid  and  uncollected.  The 
face  was  flushed  and  somewhat  congested,  her  pupils  dilated  and  inactive, 
her  heart  slow  and  heaving  in  its  action,  with  a  clanging  accentuation  of 
the  second  sound  at  the  base,  and  her  pulse  was  hard,  full,  long,  and 
incompressible.  There  was  a  little  discharge  from  the  vagina  and  some 
urine  drawn  from  the  bladder  contained  a  trace  of  albumen.  The  albu- 
minuria rendered  the  diagnosis  uncertain,  but  as  the  acuteness  in  arterial 
tension  was  unmistakable,  we  bled  her  freely  from  the  arm.  Nearly 
thirty  ounces  were  taken  and  this  without  faltering  of  the  pulse,  and, 
indeed,  before  it  became  large  and  soft.  Then  she  became  fully  conscious 
and  made  complaint  of  a  little  nausea.  As  her  bowels  were  confined,  a 
brisk  saline  purge  was  prescribed  and  a  restricted  diet.  Xext  day,  her 
doctor,  long  detained  by  matters  obstetric,  weut  with  some  anxiety  to 
visit  her.  He  found  her  downstairs  presiding  at  the  tea-table,  perfectly 
hearty  and  well.  Despite  the  facts  that  her  appearance  and  her  history 
negatived  the  existence  of  granular  kidney,  the  presence  of  albumen  in 
the  urine  rendered  me  at  first  suspicious,  but  it  never  could  be  detected 
at  any  subsequent  examination,  and  when,  a  week  or  two  ago,  I  made 
inquiry  regarding  her,  I  found  her  in  perfect  health. 

That  the  albuminuria  and  the  slight  uterine  discharge  had  a  common 
origin  in  the  high  arterial  tension,  and  that  the  state  of  coma  in  which 


52 


MACDOUGrALL,  VALUE    OF  BLOODLETTING. 


she  was  found  followed  an  unrecognized  convulsion  are  sequences  I 
think  very  probable.  In  the  existence  of  acute  vascular  pressure  lay 
the  primary  harm,  and  this  harm  bloodletting  relieved  in  a  manner 
with  which  no  other  remedy  could  cope.  This  relief  was  as  evident 
and  striking  to  those  standing  around  as  it  was  to  the  medical 
attendants. 

That  in  cases  depending  upon  menstrual  irregularity  the  excess  in 
tension  arises  from  simple  increase  in  the  volume  of  the  circulating 
fluid  is,  I  think,  likely  ;  and  hence,  in  some  of  them,  as  happened  in  the 
instance  just  related,  bloodletting  not  only  brings  relief  to  urgent  symp- 
toms, but  it  effects  a  permanent  cure. 

Here  may  well  end  my  quest.  It  is  not  without  due  deliberation 
that  I  have  recorded  these  views  with  reference  to  the  value  of  blood- 
letting, for,  although  there  has  been,  of  late,  a  decided  reaction  in  its 
favor,  there  still  exists  a  strong  prejudice  against  it,  and  where  many 
of  the  wisest  and  best  hold  opposite  opinions  it  seems  immodest  to  speak 
with  decisive  tone.  And  yet  it  is  not  necessary  when  we  speak  with 
decision  to  speak  presumptuously.  The  opinions  that  are  mine  on  this 
matter  have  grown  slowly,  and  they,  at  least,  have  this  possible  merit, 
that  as  the  result  of  experience  and  of  thought  they  have  become  con- 
victions. To  some  the  premises  upon  which  they  are  based  may  seem 
quite  inadequate,  and  the  views  wrong,  but  I  have,  nevertheless,  ven- 
tured to  narrate  them,  because  they  are  my  firm  beliefs,  faith  in  which 
has  stood  the  strong  touchstone  of  practice. 

It  was  a  proposition  of  that  wise  physician,  the  late  Dr.  Peter  M. 
Latham,  that  the  groundwork  of  rational  practice  is  to  understand  the 
value  of  single  indications,  and  the  power  of  single  remedies ;  and  as 
there  seems  to  be  no  treatment  for  which  the  indications  are  so  decisive 
— none  in  which  a  single  one  may  more  surely  point  the  way  than  for 
bloodletting — and  no  single  remedy  which,  in  necessary  circumstances, 
possesses  so  great  a  power,  I  will  finish,  and  at  the  same  time  point  the 
object  of  my  paper,  by  a  quotation  from  his  writings :  "  I  am  persuaded," 
he  says,  "  that  when  the  physician  is  called  upon  to  perform  great  things, 
even  to  arrest  destructive  disease  and  to  save  life,  his  skill  in  wielding 
the  implements  of  his  art  rests  mainly  upon  the  right  understanding  of 
simple  and  single  indications,  and  of  the  remedies  which  have  power  to 
fulfil  them." 

Carlisle. 


TAYLOE,  PRECOCIOUS  GUlfMATA. 


53 


PRECOCIOUS  GUMMATA.1 
By  R.  W.  Taylok,  M.D., 

SURGEON  TO  CHARITY  HOSPITAL,  NEW  YORK. 

The  close  and  widespread  study  of  syphilis  within  the  past  fifteen 
years  has  conclusively  shown  that  the  old  and  dogmatic  division  of  the 
disease  into  three  sharply  marked  periods  must  soon  be  very  much  mod- 
ified, or  perhaps  even  discarded,  and  that,  although  the  terms  primary, 
secondary,  and  tertiary,  as  applied  to  stages  of  syphilis,  present  the  ad- 
vantage of  clearness  and  simplicity  in  study  and  description,  and  may 
even  be  clinically  true  as  regards  a  large  number  of  cases,  yet  there  are 
very  many  in  which  such  a  division  is  inappropriate,  since  we  observe 
in  some  the  so-called  tertiary  lesions  in  the  secondary  period;  in  others 
seemingly  secondary  lesions  in  the  tertiary  period,  and  perhaps  coexist- 
ing with  well-marked  lesions  of  that  period;  or,  again,  cases  of  tertiary 
lesions  concomitant  with  secondary  lesions.  To  hold,  then,  that  super- 
ficial lesions  belong  to  and  are  only  found  in  the  early  or  secondary 
period,  and  that  they  are  followed  later  on  by  lesions  involving  the 
tissues  more  profoundly,  is  in  reality  to  sacrifice  facts  for  simplicity  of 
description.  Indeed,  one  of  the  as  yet  unsettled  problems  of  great  im- 
portance  in  syphilology  is  that  relating  to  its  periods,  classification,  and 
chronology. 

One  of  the  main  facts  which  militate  against  the  old  division  is  that 
which  has  been  so  prominently  brought  forward  of  late  years,  namely, 
that  there  are  many  lesions  and  affections  which  were  formerly  looked 
upon  as  belonging  to  the  tertiary  period,  which  are  very  frequently  ob- 
served to  assume  a  precocious  development,  appearing  more  or  less  early 
in  the  secondary  period.  Thus  we  not  infrequently  see  within  the  first 
year  of  syphilis  destructive  ulcerations  of  various  size  and  depth  which 
we  call  malignant,  precocious  syphilides.  Not  infrequently  do  we  meet 
with  cases  of  osseous  and  articular  lesions  which,  under  the  old  division, 
we  can  only  term  precocious  since  they  appear  in  the  so-called  secon- 
dary stage.  Marked  instances  of  early  gummatous  development  are 
seen  plainly  in  the  gumma  of  the  iris,  and  again  severe  infiltrations  of 
the  pharynx  and  larynx  are  not  infrequently  observed  early  in  the  first 
year  of  the  disease.  Then,  again,  observations  made  within  the  last 
decade  have  shown  that  affections  of  the  nervous  system,  which  at  one 
time  was  thought  to  be  spared  by  the  syphilitic  virus,  and  in  later  times 
attacked  only  in  its  tertiary  stage,  may  develop  within  the  first  six 
months  of  syphilitic  infection.    In  considering  this  subject  of  the  rela- 

1  Read  before  the  American  Dermatological  Association  August  25,  1886. 


54 


TAYLOR,  PRECOCIOUS  GUJI1IATA. 


tionship  of  secondary  to  tertiary  lesions,  that  eminent  surgeon,  Mr.  Jona- 
than Hutchinson,1  says : 

"What  has  been  named  a  'gumma'  has  been  supposed  to  be  characteristic 
of  the  tertiary  stage.  Opinions  have,  however,  been  changing  respecting 
several,  if  not  all,  of  these  points.  Cases  have  been  recognized  in  which  the 
various  conditions  referred  to  were  met  with  so  early  in  the  disease,  and  in 
such  close  combinations  with  each  other,  that  the  only  explanation  seerned  to 
be  that  the  disease  had  run  an  unusually  rapid  course,  and  had  reached  its 
last  stage  before  it  had  well  finished  its  first.  By  degrees  we  are,  however, 
arriving  at  another  interpretation  of  such  facts,  and  are  beginning  to  see 
that  the  old  classifications  of  the  phenomena  cannot  hold  their  ground,  and 
that  we  must  seek  for  other  characters  by  which  to  distinguish  the  secondary 
and  tertiary  stages.  Not,  indeed,  that  the  old  observations  are  wholly  wrong; 
this  would  be  exceedingly  improbable,  and  its  mere  assertion  would  very 
properly  lead  to  much  distrust  of  any  modern  conclusion  which  might  seek 
to  supplant  them.  Speaking  loosely,  and  in  a  general  way,  it  is  still  true  that 
visceral  affections,  gummata,  deep  ulceration  and  periostitis  belong  to  the 
tertiary  stage.  It  is  only  when  these  facts  are  brought  forward  as  if  they 
were  constant  and  sufficient  in  themselves  to  form  the  basis  of  classification, 
that  we  are  compelled  to  make  protest." 

He  then  continues : 

"  Permit  me  to  illustrate  what  I  mean  by  the  citation  of  a  case.  A  young 
man,  aged  twenty-one,  too  young,  let  me  note,  for  it  to  be  likely  that  he  ever 
had  syphilis  before,  was  admitted  into  the  London  Hospital  under  my  col- 
league, Dr.  Langdon  Down.  He  had  still  the  remains  of  a  hard  chancre  on 
him,  and  he  was  covered  by  a  papular  rash,  which  was  ulcerating  in  places. 
The  date  which  he  assigned  to  the  beginning  of  the  affection  was  only  four 
months  previously.  He  died  suddenly  and  unexpectedly.  The  necropsy 
showed  gummata  in  both  testicles,  in  the  spleen,  and  in  the  heart,  death 
having  been  caused  by  the  softening  and  ulceration  of  the  latter." 

Though  Mr.  Hutchinson  thus  shows  the  shortcomings  of  the  old  clas- 
sification of  syphilis,  he  does  not  attempt  to  establish  a  new  one.  In  this 
he  is,  in  my  judgment,  wise,  seeing  that  in  our  knowledge  of  the  natural 
history  of  syphilis  there  are  yet  many  lacuna?,  notably  in  that  of  early 
visceral  lesions.  In  Germany,  also,  the  insufficiencies  of  the  old  classi- 
fication have  been  treated  of  in  an  excellent  article  by  Finger,2  who, 
however,  has  no  new  one  to  offer. 

Though  to-day  there  are  comprehensive  descriptions  of  precocious 
nervous,  osseous,  articular,  ocular,  and  superficial  ulcerative  dermal 
affections  due  to  syphilis,  a  systematic  description  of  the  clinical  history 
of  precocious  gummata  is  wanting. 

It  must,  in  justice,  here  be  stated  that  our  knowledge  of  many  of  the 
precocious  affections'  of  syphilis  is  in  a  large  measure  due  to  the  writings 
of  that  eminent  syphilographer,  C.  Mauriac.  His  paper,  entitled  "  Cas 
de  syphilis  gommeuse  precoce  et  refractaire  a  iodure  de  potassium," 
Paris,  1874,  is,  according  to  my  reading,  the  first  contribution  to  the 

1  Lettsomian  Lectures  on  Some  Moot  Points  in  the  Natural  History  of  Sj-pkilis.  British  Medical 
Journal,  January  23,  1886. 

8  Ueber  die  Koexistenz  der  sogenanten  secundaren  und  tertiaren  Syphilisformen.  Wien.  med. 
Wochenschrift,  Nos.  1  and  3,  1882. 


TAYLOR,   PRECOCIOUS   GUMMATA.  55 

subject  of  precocious  gummata,  and  this,  with  his  latter  paper,  "  Memoire 
sur  les  affections  precoce  du  tissue  cellulaire  subcutanee,"1  constitutes  up 
to  this  time  the  literature  of  this  form  of  eruption. 

In  the  present  essay  the  divisions  and  clinical  descriptions  are  based 
wholly  on  my  own  observation  and  study  during  a  period  of  many  years, 
aided  at  times  by  the  facts  observed  by  Mauriac.  In  many  points  my 
experience  accords  with  that  of  this  painstaking  observer,  while  in  others 
it  is  more  or  less  at  variance. 

I  propose  to  present  the  clinical  histories  of  a  selected  number  of  my 
cases,  from  which  I  think  I  can  trace  a  clear  and  satisfactory  description 
of  these  not  common  nor  yet  infrequent  eruptions. 

My  studies  have  convinced  me  that  there  are  three  forms  of  the  pre- 
cocious gummata:  The  first,  the  generalized  form;  the  second,  the  local- 
ized form ;  and  the  third,  the  neurotic  form,  which  in  some  of  its  features 
resembles  erythema  nodosum.  Of  each  of  these  three  forms,  moreover, 
there  are  two  varieties:  a  resolutive,  or  non-ulcerative,  and  an  ulcerative 
variety. 

I.  The  Generalized  Form  of  Precocious  Gummata. 

A  clear  idea  of  this  form  of  syphilide  is  presented  by  the  following 
case : 

Case  I. — A  merchant,  aged  thirty-six,  came  under  my  observation  in 
May,  1885.  He  was  a  tall,  thin  man,  of  exceedingly  nervous  tempera- 
ment, never  very  strong,  who  continually  overtaxed  himself  mentally 
and  physically,  and  subordinated  to  business  every  pleasure  and  relaxa- 
tion. Excepting  several  attacks  of  gonorrhoea,  and  more  or  less  pro- 
longed periods  of  extreme  debility,  he  had  had  no  real  sickness  in  his 
life.  He  came  of  excellent  stock.  In  January,  1885,  he  had  a  large 
indurated  chancre,  with  marked  inguinal  adenopathy,  which  was  fol- 
lowed late  in  February  by  a  roseola  and  papular  syphilide,  fall  of  hair, 
rheumatoid  pains,  emaciation,  and  asthenia.  For  these  he  had  been 
treated  by  an  out-of-town  physician  in  a  proper  manner. 

Late  in  May,  three  months  after  the  evolution  of  the  secondary  period 
of  syphilis,  he  came  to  me,  at  the  advice  of  his  physician  presenting  the 
following  symptoms.  On  the  scalp  a  tendency  to  loss  of  hair,  mucous 
patches  in  pharynx,  and'  over  the  body  a  declining  papular  syphilide, 
interspersed  with  slight  maculations  of  what  had  been  a  deep-tinted 
roseola.  Amid  these  retrogressing  lesions  was  the  eruption  which  is  of 
interest  in  this  paper.  Over  the  nucha  and  the  shoulders,  on  the  outer 
aspect  of  the  arms,  particularly  over  the  elbow,  over  the  gluteal  region, 
quite  copiously  on  the  outer  and  anterior  part  of  the  thighs  and  legs, 
and  sparsely  on  the  inner  aspect  of  these  members  was  scattered  an  erup- 
tion of  tubercles,  varying  in  size  from  a  lima  bean  to  a  walnut,  which 
numbered  by  actual  count  more  than  forty.  These  tumors  were  seated 
firmly  in  the  skin,  involving  its  whole  thickness,  besides  some  of  its 

1  Annales  de  Derniatologie  et  do  Syphiligrapliie,  1880  and  1SS1,  and  Leyons  sur  les  Maladies  Veuo- 
riennes,  Paris,  1883 


56  TAYLOR,  PRECOCIOUS  GrUMMAT  A. 

underlying  connective  tissue,  were  easily  movable,  and  sharply  circum- 
scribed. They  were  of  a  dull  red  color,  some  of  them  level  with  the 
plane  of  the  skin,  while  others,  and  particularly  the  larger  ones,  were  in 
a  moderate  degree  salient.  They  were  in  general  covered  with  normal 
epithelium. 

Amid  these  well-developed  tumors  were  fully  fifteen  very  minute 
ones,  of  which  several  could  not  be  seen  by  the  naked  eye,  but  on 
searching  for  them  presented  to  the  tip  of  the  finger  a  feeling  of  movable, 
circumscribed  infiltration  in  the  deeper  portion  of  the  derma.  Others 
of  these  incipient  tubercles,  being  like  those  just  described,  of  the  size  of 
a  pea,  showed,  upon  examination,  that  they  were  infiltrations  which  had 
begun  coincidently  in  the  skin  and  connective  tissue,  while  it  was 
evident  that  in  the  former  the  morbid  process  began  in  the  superficial 
layers  of  the  connective  tissue,  and  that  they  gradually  contracted  ad- 
hesions with  and  invaded  the  whole  derma.  The  only  further  point  of 
interest  of  this  case  in  this  connection,  is  that  a  few  of  the  larger  and 
older  tubercles  underwent  slight  and  superficial  ulceration,  while  the 
majority  were  cured  by  local  and  constitutional  treatment  within  a 
month.  i 

The  period  of  time  occupied  by  the  evolution  of  the  eruption  up  to 
the  date  of  my  first  examination  was,  as  nearly  as  could  be  determined, 
two  weeks.  During  the  whole  course  of  the  eruption  the  subjective 
symptoms  had  been  very  slight  and  were  limited  to  a  feeling  of  slight 
uneasiness  and  impediment  to  locomotion. 

I  may  here  add  that  the  question  in  the  mind  of  the  attending  physi- 
cian, who  was  a  very  intelligent  man,  I  only  seeing  the  case  at  varying 
intervals  in  consultation,  was,  whether  the  eruption  I  have  just  described 
was  really  of  syphilitic  origin,  or  whether  it  was  a  coincident  furunculosis 
of  low  grade  and  of  aborted  form.  He  very  pertinently  remarked  that 
it  seemed  strange  that  such  superficial  lesions  as  roseola,  papules,  etc., 
should  be  followed  so  quickly  by  lesions  so  deep-seated  as  were  these 
gummatous  infiltrations. 

The  foregoing  case  may  be  taken  as  typical  of  the  first,  earliest,  and 
most  common  form  of  the  precocious  gummata.  It  will  be  noted  that 
while  in  its  general  and  symmetrical  distribution  the  eruption  presented 
the  features  of  the  early  and,  we  may  perhaps  say,  exanthematic  syphi- 
lides  in  the  intensity  and  profundity  of  the  morbid  process,  it  partakes  of 
the  character  of  the  late  or  tertiary  lesions.  In  my  experience  this  par- 
ticular form  of  eruption,  while  not  rare,  is  not  very  common.  I  usually 
see  four  or  five  of  such  cases  every  year  in  hospital  and  two  or  three  in 
private  practice. 

These  cases  present  considerable  uniformity,  and  although  to  the  ex- 
perienced physician  they  usually  offer  no  difficulty  of  diagnosis,  I  have 
often  seen  them  prove  stumbling  blocks  to  the  younger  men  and  some- 
times even  to  older  ones. 

This  eruption  may  appear  as  early  as  the  second  month,  and  in  the 
third,  fourth,  and  sixth.    I  have  observed  that  the  earlier  the  date  of 


TAYLOK,   PRECOCIOUS  GUMMATA. 


57 


the  appearance  in  general  the  more  extensive  is  the  eruption  and  the 
more  numerous  the  gummatous  tumors,  and  that  while  it  is  the  rule  to 
see  many  of  them,  thirty,  forty,  or  even  sixty  or  seventy,  cases  will  be  ob- 
served when  as  small  a  number  as  fifteen  or  twenty  tumors  are  present. 
Not  infrequently  do  we  see  the  evolution  of  the  eruption  following  or 
even  coincidently  with  the  existence  of  a  general  roseolous,  a  papular, 
or  even  pustular  syphilide.  It  is  not  uncommon  to  find  coincident 
gummy  infiltration  into  the  pharyngeal  walls  or  into  the  mucous  mem- 
brane of  the  roof  of  the  mouth,  or  even  less  intense  lesions  of  these  parts. 
Serous  and  gummous  iritis,  neuralgic  phenomena,  even  such  grave  affec- 
tions as  hemiplegia,  paraplegia,  and  minor  palsies  may  also  be  observed 
to  be  coincident  with  or  follow  closely  upon  the  evolution  of  this  erup- 
tion. Many  observations  which  I  have  made  have  convinced  me  that 
in  most  cases  there  is  an  accompanying  well-marked  febrile  movement 
just  preceding  and  during  the  outbreak.  In  some  of  the  milder  cases 
the  temperature  may  be  elevated  from  one  to  two  degrees,  while  in 
others,  particularly  in  those  of  extensive  eruption,  the  thermometer 
registers  in  the  evening  102°  or  103°  P .,  with  a  decline  of  two  or  more 
degrees  in  the  morning.  Then,  again,  the  fever  may  be  slight  and  con- 
tinuous, while  in  cases  attended  with  much  cachexia,  a  continuous  high 
fever  is  occasionally  observed. 

This  form  of  gummatous  eruption  attacks  both  males  and  females  in 
about  equal  numbers ;  my  own  observations  tend  to  convince  me  that 
some  condition  of  lowered  vitality  or  impaired  nutrition  is  at  the  root  of 
it  and  of  other  forms  of  early  gummata.  Thus  I  have  met  with  it  in 
persons  of  naturally  poor  fibre,  in  those  of  studious  and  sedentary  habits, 
in  persons  exhausted  by  the  cares  and  confinements  of  business,  and  last, 
but  foremost,  in  those  who  are  habituated  to  the  excessive  use  of  alco- 
holics. If  the  question  was  put  to  me,  "  In  whom  do  you  most  fre- 
quently observe  severe  and  precocious  syphilides  ? "  I  should  answer 
promptly,  first,  in  those  whose  nutrition  is  impaired  by  alcohol ;  second, 
in  those  who  suffer  from  renal  and  hepatic  diseases ;  and,  third,  in 
those  having  these  visceral  lesions  and,  besides,  who  have  been  addicted 
to  alcoholics.  I  am  not  as  much  impressed  as  some  observers  are  as  to  the 
malignancy  of  syphilis  in  strumous  subjects.  Very  many  such  patients 
become  sorely  afflicted  by  syphilis,  yet  in  many  that  disease  runs  its 
course  unattended  by  severe  precocious  lesions  or  even  with  late  lesions 
of  much  severity.  I  have  reached  the  conclusion  from  extended  obser- 
vation that  in  the  so-called  scrofulous  person,  provided  his  or  her  habits 
of  life  are  good,  there  is  not  an  unvarying  tendency  to  malignant  pre- 
cocious syphilis.  It  is  true,  I  have  seen  early  and  malignant  forms  of 
syphilis  in  strumous  persons,  but  not  in  such  numbers  as  to  warrant  me 
in  placing  struma  in  the  front  rank  of  its  causes. 

This  form  of  eruption  is  found  in  both  old  and  young,  though  my  sta- 


58 


TAYLOR,  PRECOCIOUS  G-UMMATA. 


tistics  show  that  the  greater  number  of  my  patients  were  between  twenty 
and  thirty-five  and  after  fifty  years.  My  opinion  is  in  accord  with  most 
syphilographers  that  syphilis  in  persons  beyond  fifty  years  of  age  is  fre- 
quently severe ;  that  its  lesions  are  often  precocious,  grave,  and  extensive ; 
and  that  the  diathesis  has  a  tendency  to  modify,  to  engraft  itself  upon 
and  often  to  intensify  previous  morbid  processes  or  affections,  local  or 
general.  I  have  repeatedly  seen  instances  of  this  malignant  action,  and 
I  have  very  frequently  seen  the  form  of  precocious  syphilide  now  under 
consideration  in  old  subjects. 

Malaria  very  frequently  acts  as  a  formidable  complication  of  syphilis, 
and  some  of  the  most  rebellious  cases  that  I  have  treated  were  in  per- 
sons whose  systems,  prior  to  syphilitic  infection,  had  been  debilitated  by 
its  virus.  In  such  cases  I  think  that  we  more  frequently  see  precocious 
cerebral  and  nervous  symptoms,  and  not  infrequently  early  hepatic 
disturbances,  of  greater  or  less  severity.  In  these  cases  of  mixed 
diatheses,  however,  the  syphilides  often  run  an  active  and  severe  course, 
and  precocious  gummata  not  infrequently  attack  them. 

The  clinical  history  of  this  form  of  precocious  syphilide  then  is  as 
follows :  As  early  as  the  eighth  week  of  infection,  rarely  earlier,  the 
patient  notices  either  small  circumscribed  swellings  under  the  skin, 
generally  unattended  with  pain  and  only  perceptible  to  the  touch,  or 
this  stage  of  the  eruption  may  escape  him  and  his  attention  is  at  first 
arrested  by  a  number  of  bright  red  spots.  Quite  frequently  the  patient 
comes  with  the  statement  that  blind  boils  are  breaking  out  all  over  him. 
Examined  early  in  their  history  these  gummata  are  found  to  be  round 
tumors  of  the  size  of  a  bean,  deeply  set  in  the  skin,  having  a  bright  red 
color  which,  at  the  first,  is  dissipated  by  pressure,  but  becoming  deeper, 
more  sombre  and  permanent  in  color  later  on.  They  increase  periphe- 
rally quite  rapidly,  so  that  within  a  week  or  ten  days  they  may  attain 
an  area  of  an  inch,  or  an  inch  and  a  half.  .Then  again  their  growth 
may  be  slower.  In  general  a  goodly  number  of  tumors  appear  scattered 
symmetrically  over  the  whole  body.  As  they  grow  they  are  followed 
by  new  ones  which  come  along  with  greater  or  less  rapidity,  in  propor- 
tion as  internal  medication  is  pushed.  If  a  correct  diagnosis  is  at  once 
made  and  appropriate  treatment  instituted,  the  first  crop  may  be  the 
only  one  and  that  may  be  promptly  dissipated.  Unaffected  by  medi- 
cine, their  evolution  continues  and  in  a  fortnight  the  arms,  forearms,, 
perhaps  the  scapular  region,  not  infrequently,  but  not  as  a  rule,  the  back 
and  anterior  surface  of  the  trunk,  the  gluteal  regions,  thighs,  and  legs 
are  invaded  by  these  tumors. 

The  course  of  these  gummata  is,  in  general,  quite  regular  and  not 
subject  to  great  variation.  When  developed  they  present  a  quite  firm 
sensation  and  this  may  be  termed  the  period  of  condensation.  As  they 
grow  older  the  red  color  becomes  rather  coppery,  and  while  the  periphery 


TAYLOR,   PRECOCIOUS  GU11MATA. 


59 


of  the  tumor  may  or  may  not  seem  firm,  the  central  portions  appear 
softer  to  the  touch,  conveying  the  impression  that  the  tissues  are  per- 
meated with  a  thick  fluid.  This  we  may  denominate  the  stage  of  soften- 
ing, and  is  found  to  be  of  varying  degrees  in  different  cases.  In  some 
instances  there  is  simply  a  soft  and  yielding  sensation  conveyed  to  the 
finger  tip,  while  in  others  a  feeling  of  slight  fluctuation  is  noticed.  To 
the  inexperienced  in  the  latter  case  these  tumors  may  give  the  impres- 
sion of  being  abscesses  and  suggest  the  use  of  the  knife.  But  such  a 
procedure  should  not  be  resorted  to,  since  resolution  may  take  place 
under  the  influence  of  treatment,  even  when  the  condition  of  softening  is 
well  marked.  In  the  majority  of  the  cases  there  is  not  abscess  formation, 
out  rather  a  liquefaction  of  the  gummy  infiltration,  which  is  in  general 
promptly  absorbed.  In  the  non-ulcerating  or  resolutive  variety  of  pre- 
cocious gummata,  which  we  are  now  considering,  the  further  progress  of 
the  tumors  is  as  follows:  They  gradually  become  flatter,  the  borders 
melt  away  slowly,  and  the  color  pari  passu  fades  until  the  normal  hue 
or  a  coppery  pigmentation  of  the  skin  is  reached,  which  occurs  soonest 
on  the  trunk  and  upper  extremities  and  latest  on  the  legs.  On  the 
latter  situation  the  stage  of  softening  may  continue  until  the  stage 
of  ulceration  sets  in.  Here,  also,  these  tumors  frequently  take  on 
inflammatory  action  when  complicated  with  varicose  veins,  with  oedema 
and  chronic  eczema  and  erysipelas.  The  time  occupied  in  the  full  de- 
velopment of  these  tumors  is  usually  from  ten  days  to  two  weeks,  and 
after  that  their  period  of  duration  is  variable.  They  may,  under  treat- 
ment and  care,  promptly  retrogress,  and  again  may  remain  in  an  indo- 
lent condition  in  the  second  stage  indefinitely.  The  traces  left  by  them 
are  generally  very  slight  and  not  permanent,  being  simply  slight  hyper- 
emia and  scaling  and  coppery  pigmentation.  Then  again,  in  long- 
standing resolutive  cases,  after  absorption  has  taken  place  distinct  loss 
of  tissue  may  be  noticed  in  a  depressed  cicatrix,  which,  however,  is  not 
as  profound  as  those  left  by  the  gummata  of  later  periods.  Not  uncom- 
monly, new  and  sparse  crops  of  tumors  appear  while  the  general  eruption 
is  in  process  of  absorption. 

Having  thus  quite  fully  described  the  non-ulcerative  or  resolutive 
form  of  this  very  precocious  gummatous  eruption,  a  few  words  will 
suffice  to  bring  out  the  features  of  the  ulcerative  variety.  While  in  the 
first  variety  there  is  usually  little  or  no  tendency  in  the  tumors  to  necro- 
biotic  action,  in  the  second  variety  this  condition  is  seen  quite  early. 
The  stage  of  condensation  is  very  short,  and  softening  in  a  marked 
degree  is  observed  in  a  fe^v  days.  The  centre  of  the  tumors  assumes  a 
dark  red  color  in  one  or  in  several  spots,  and  a  sensation  of  fluid  under 
the  epidermis  is  distinctly  made  out.  Then  slight  ulceration  may  occur 
in  spots,  often  at  the  openings  of  the  hair  and  sebaceous  follicles,  and 
very  soon  the  epidermal  roof  of  the  tumor  melts  away,  and  we  soon  see 


60 


TAYLOR,  PRECOCIOUS  GUMMATA 


the  gummatous  ulcer  with  its  slightly  thickened,  reddened,  undermined, 
and  perhaps  everted  edges,  and  its  floor  of  a  greenish-red,  bathed  in  an 
unhealthy  sanious  pus.  As  a  rule,  however,  these  ulcers  are  more 
superficial  than  the  later  ones.  Their  floor  is  less  deep,  the  edges  less 
undermined  and  everted,  and  the  whole  appearance  indicates  that  the 
destruction  is  less  profound.  I  have  seen  instances  of  this  variety  in 
which  as  many  as  forty  tumors  underwent  degeneration. 

Having  reached  the  stage  of  ulceration,  the  further  course  is  indefinite, 
and  it  depends  entirely  upon  the  treatment,  external  and  internal,  which 
is  adopted.  The  concomitant  symptoms  of  this  variety  of  the  gummous 
syphilide  are  in  general  like  those  of  the  resolutive  variety,  only  that 
they  are  usually  more  intense  and  accentuated.  The  fever  is  higher, 
the  malaise  more  pronounced,  and  the  general  condition  of  the  patient 
rather  worse. 

Usually  there  is  no  difficulty  of  diagnosis  of  this  variety  of  precocious 
gummata.  The  infection  is  so  recent  that  a  history  of  syphilis  is  easily 
obtained  and  then  all  doubt  as  to  the  nature  of  the  tumors  is  removed. 
I  have  seen  them,  however,  mistaken  for  aborted  furuncles  and  regarded 
as  rheumatic  tumors,  as  scrofulous  swellings,  and  in  a  case  in  which  the 
initial  lesion  was  seated  on  the  index  finger  and  was  accompanied  by 
severe  constitutional  symptoms  and  an  active  angio-leucitis  of  the  arm, 
they  were  thought  to  be  the  result  of  purulent  infection. 

II.  The  Localized  Foem. 

The  second  variety  of  precocious  gummata  usually  appears  somewhat 
later  than  the  one  just  described.  In  exceptional  cases  I  have  seen  the 
eruption  as  early  as  the  third  month  of  syphilis,  though  my  notes  show 
that  in  the  greater  number  of  cases  the  date  of  appearance  was  the  fifth, 
sixth,  or  eighth  month  of  infection  and  even  as  late  as  one  year.  Like  the 
first  variety,  the  evolution  of  these  tumors  is  aphlegmasic,  rather  more 
insidious  and  indolent  than  that  of  the  first  variety,  and,  in  short,  par- 
taking of  their  characteristics  to  a  certain  extent  and,  also,  of  those  of 
the  gummata  of  the  tertiary  period. 

In  the  second  variety,  also,  we  find  some  cases  in  which  resolution 
takes  place,  while  in  others  the  stage  of  softening  goes  on  to  ulceration. 
While  in  the  first  variety  the  tumors  are  smaller,  more  numerous,  and 
more  copiously  and  symmetrically  distributed,  in  the  second  they  are.  as 
a  rule,  larger,  less  numerous,  and,  though  generally  symmetrically 
placed,  occasionally  they  are  unsymmetrical,  existing  upon  one  region 
and  absent  on  its  fellow  of  the  opposite  side. 

As  a  rule,  th^y  are  met  with  in  the  same  class  of  persons  as  the  first 
variety  is,  namely,  in  the  aged,  and  those  given  to  excess  in  alcoholics, 
in  persons  of  strumous  tendency,  in  subjects  debilitated  by  any  exhaust- 
ing cause  or  adynamic  influence,  such,  for  instance,  as  visceral  disease, 


TAYLOR,   PRECOCIOUS  GUMMATA. 


61 


fevers,  pneumonia,  diphtheria,  etc.,  and  in  those  reduced  by  chronic 
malaria.  Then,  again,  I  have  seen  this  eruption  in  patients  who  could 
not  be  classed  in  any  of  these  categories,  who  had  never  had  any  sick- 
ness— yet,  as  they  remarked,  had  never  been  strong  ;  in  short,  persons  of 
poor  fibre.  While  there  may  be  a  slight  prodromal  or  accompanying 
fever,  it  is  usually  absent,  and  the  patients  may  not  complain  of  any 
unusual  intensification  of  their  morbid  condition. 

The  following  case  will  answer  well  as  a  prototype  of  this  second  form 
of  precocious  syphilide  in  its  full  development ;  while  very  brief  notes 
of  other  cases  will  be  of  service  in  showing  its  more  restricted  and  less 
symmetrical  distribution. 

Case  II. — A  female,  aged  twenty-four,  a  blonde,  fat  and  flabby,  came 
under  my  observation  at  Charity  Hospital  in  October,  1883.  She  had 
been  in  the  hospital  at  different  times  for  gonorrhoea  and  chancroids, 
was  a  woman  of  the  town,  and  addicted  to  drink  and  dissipation.  In 
April,  1883,  she  had  an  insignificant  ulcer  at  the  fourchette,  which  was 
followed  by  inguinal  adenopathy,  fall  of  hair,  a  severe  attack  of  mucous 
patches  of  mouth,  throat,  and  larynx,  and  a  disseminated  and  very 
copious  papulo-pustular  syphilide.  She  was  treated  at  a  dispensary, 
but  was  negligent  in  following  advice,  and  generally  careless  of  her 
health.  In  September,  five  months  after  infection,  she  presented  evi- 
dence over  the  whole  body  of  a  small  miliary  papular  syphilide. 

She  entered  the  hospital  on  account  of  a  number  of  tumors  on  her  legs 
which  began  to  appear  about  a  week  before.  At  the  examination  I 
found,  on  the  outer  aspect  of  the  forearms,  over  both  gluteal  regions,  and 
on  the  lower  half  of  the  leg,  a  number  of  tumors.  These  were  oval  in 
shape,  following  the  longitudinal  axis  of  the  limbs,  but  obliquely  trans- 
verse at  the  gluteal  regions,  slightly  elevated,  and  were  felt  to  involve 
the  whole  thickness  of  the  skin,  and  part  of  its  subcutaneous  tissue. 
Their  color  was  a  pronounced  red,  tending  toward  brown ;  they  were 
covered  with  a  tolerably  perfect  epidermis,  and  surrounded  on  the  legs 
by  a  bright  red  areola.  Elsewhere  the  deep  red  color  of  the  tumors 
stopped  sharply  at  their  borders.  The  largest  of  them,  which  were  on 
the  outer  side  of  the  legs,  were  about  two  and  a  half  inches  in  length, 
by  one  and  a  half  in  breadth,  while  the  others  varied  in  size  until  the 
smallest  were  reached,  which  were  less  than  an  inch  long.  In  all  there 
were  about  fourteen.  The  woman's  stomach  was  so  much  deranged, 
and  her  health  so  debilitated,  that  mercury  in  any  form,  or  by  any 
method  of  administration,  was  temporarily  out  of  the  question.  The 
treatment  was,  therefore,  directed  to  improvement  of  the  appetite,  and 
invigoration  of  the  system. 

While  under  this  course,  several  subcutaneous  tumors  developed 
quite  quickly,  say  within  ten  days,  on  the  outer  aspects  of  both  the  fore- 
arms and  the  legs.  They  could  be  distinctly  felt  at  first  as  localized, 
sharply  limited  infiltrations,  without  any  subjective  symptoms  whatever. 
In  this  condition  they  were  followed  carefully  from  day  to  day,  when  in 
two  weeks  they  had  attained  an  area  of  an  inch  and  a  half  by  one  inch, 
having  in  the  meantime  fused  themselves  with  the  skin  lying  above 
them,  and  come  to  present  features  essentially  like  those  of  their  prede- 
cessors.  The  patient  presented  very  slight  febrile  symptoms,  complained 


62 


TAYLOR,  PRECOCIOUS  GUMMATA. 


of  no  pain,  but  simply  a  tense  feeling  in  the  arms  and  legs.  Later  on, 
under  a  mixed  treatment,  these  tumors  slowly  disappeared,  having  in 
the  meantime  been  increased  by  the  addition  of  four  more.  In  their 
fully  developed  state — that  is,  when  about  two  weeks  old — they  were 
hard  and  firm,  but  later  on,  they  became  softer,  especially  in  their  cen- 
tral portion,  producing  a  very  slight  sensation  of  fluctuation,  or,  perhaps, 
I  might  say,  bogginess  of  the  tissues.  They  never  advanced  toward 
ulceration  further  than  this.  The  redness  grew  more  brownish,  and  then 
gradually  faded,  until  at  last,  in  the  more  dependent  ones,  slight  pig- 
mentation remained,  while,  in  the  remaining,  total  resolution  occurred 
without  leaving  any  trace.  The  patient  was  under  observation  for  ten 
weeks. 

In  contrast  with  this  case  of  general  and  symmetrical  distribution,  the 
following  are  of  interest : 

Case  III. — A  female,  aged  twenty-nine,  in  the  seventh  month  of 
syphilis,  had  several  such  tumors  on  the  right  leg,  two  on  the  left  arm, 
and  two  on  the  scalp,  over  the  right  temporo-parietal  region. 

Case  IV. — A  man,  aged  twenty,  six  months  after  infection  had 
several  tumors  on  the  legs,  one  on  the  right  side  of  the  forehead,  and 
one  on  the  chin. 

Case  V. — A  female,  aged  forty-five,  in  the  tenth  month  of  syphilis, 
had  several  tumors  on  the  outer  side  of  both  forearms,  and  one  on  the 
left  parotid  region  and  infiltration  into  the  soft  palate. 

The  clinical  history  of  this  variety  of  gummatous  syphilis  is  so  similar 
to  that  of  the  first  that  extended  description  is  unnecessary.  The 
appearance  of  the  tumors  is  the  same,  except  that  they  are  usually  larger, 
perhaps  not  as  much  elevated  as  those  of  the  first  form.  There  is  the 
same  stage  of  condensation,  which  is  slightly  longer,  then  follows  that 
of  softening,  which  is  even  more  aphlegmasic  than  in  the  first  form.  On 
the  legs  such  complications  as  chronic  eczema,  phthiriasis,  oedema,  vari- 
cose veins,  and  erysipelas,  often  much  modify  and  intensify  the  course 
of  these  tumors.  If  resolution  takes  place,  the  same  process  and  features 
are  observed  as  I  have  already  described.  If  ulceration  occurs  we  find 
the  same  softening  in  one  or  more  central  spots,  which  become  of  a  deep 
red  or  black  color,  then  the  gradual  melting  away  of  the  skin  until  the 
well-marked  gummatous  ulcer  is  left.  '  As  in  the  first  variety  all  the 
tumors  may  undergo  this  necrobiotic  action,  so  in  this  form  one  or  more 
may  thus  succumb,  and  generally  those  on  the  legs.  The  resulting  ulcers 
are  usually  large  and  deep,  and  correspondingly  slower  in  healing.  On 
the  legs  this  eruption  is  frequently  accompanied  by  a  sensation  of 
uneasiness  and  heat,  and  locomotion  is  more  difficult.  Elsewhere  little, 
if  any,  discomfort  is  experienced,  except  on  the  forearms,  where  a  feel- 
ing of  tension  is  often  complained  of. 

In  general,  the  diagnosis  of  this  form  of  syphilide  is  easy,  particularly 
when  the  tumors  are  numerous,  and  symmetrically  distributed.  In  the 
cases  in  which  the  tumors  are  sparse  and  localized,  errors  in  diagnosis 


TAYLOR,  PRECOCIOUS   GUMMATA.  68 

are  not  infrequently  made.  It  is  important  to  bear  in  mind  that  the 
regions  of  the  head  and  face  are  particularly  susceptible  to  this  form  of 
precocious  syphilide.  When  thus  seated  in  these  regions  it  is  quite 
frequently  found  that  there  is  also  infiltration  into  the  pharyngeal  walls, 
and  perhaps  into  the  mucous  membrane  of  the  mouth. 

I  would  not  be  understood  as  limiting  the  date  of  evolution  of  this 
syphilide  to  the  first  year  of  syphilis,  since  it  unquestionably  appears 
later.  As  the  diathesis  grows  old,  however,  the  eruption  generally  is 
less  copious,  less  symmetrical,  and  is  more  insidious,  aphlegmasic,  and 
limited  in  extent,  becoming  more  and  more  like  the  tertiary  form. 

III.  The  Neurotic  Form,  Presenting  Points  of  Resemblance  to 
Erythema  Nodosum. 

Case  VI. — A  female,  thirty-seven  years  old,  married,  mother  of  three 
children,  having  suffered  from  eczema  and  severe  attacks  of  supra- 
orbital neuralgia,  accompanied  by  gastric  disorder  for  years,  was  in- 
fected with  syphilis  by  her  husband  in  the  winter  of  1881.  She  was  a 
thick-set,  fat,  and  phlegmatic  lady,  and  had  never  been  robust  and 
strong.  The  secondary  manifestations  were  quite  severe,  a  roseola  being 
soon  followed  by  a  copious  papular  syphilide,  distressing  angina,  and 
rheumatoid  pains.  She  lived  in  a  neighboring  city  and  was  carefully 
treated  with  mercurials  by  her  family  physician. 

In  the  month  of  February,  1882,  she  was  brought  to  me  and  presented 
the  following  symptoms:  She  had  complained  of  excruciating  nocturnal 
cephalalgia  for  about  ten  days.  The  cervical,  epitrochlear,  and  inguinal 
ganglia  were  much  enlarged  and  over  the  arms  and  trunk  was  a  declin- 
ing papular  syphilide.  The  chief  object  of  her  visit  was  to  determine 
the  nature  of  a  number  of  swellings  on  various  portions  of  the  body. 
On  the  outer  aspect  of  the  shoulders  were  several  oval  tumors  of  a  bright 
rosy  red,  slightly  elevated  and  convex,  having  a  firm  consistence  and 
sharply  marginated.  Their  length  was  three-quarters  of  an  inch,  their 
diameter  half  an  inch.  On  the  infra-clavicular  regions  were  two  tumors, 
symmetrically  placed,  slightly  larger  than  the  others,  and  on  each  fore- 
arm were  two  similar  tumors.  On  each  of  the  legs,  on  the  antero- 
external  surface,  were  several  more  of  larger  size,  distinctly  elevated,  flat, 
and  surrounded  by  an  cedematous  margin.  Their  surfaces  were  firm 
and  the  epidermis  quite  tense.  The  color  was  of  a  sombre  red.  The 
story  told  by  the  patient  was,  that  ten  days  previously,  when  suffering 
from  severe  headache,  which  was  worse  at  night,  she  noticed  a  sense  of 
heat  and  a  soreness  as  if  from  a  blow  or  a  bruise  in  the  forearms,  shoul- 
ders, and  more  severely  in  the  legs.  On  rubbing  these  regions  she  felt 
lumps  under  the  skin,  which,  in  two  or  three  days,  developed  into  the 
red  tumors  just  described.  While  these  tumors  were  forming  she  was 
further  affected  with  lancinating  pains  of  intermittent  character  in  the 
outer  aspect  of  both  thighs,  beginning  at  the  anterior  superior  spine  of 
the  ilia  and  running  down  to  the  knee.  Examination  at  the  time 
showed  that  under  the  skin,  on  the  antero-extemal  surface  of  both 
thighs,  were  two  irregular  oval  plaques  of  induration  fully  two  inches 
long.  Above  them  the  skin  was  freely  movable  and  by  their  inferior 
surface  thev  were  free.    No  redness  of  the  skin  was  seen  at  this  time. 


64: 


TAYLOR,  PRECOCIOUS  GUMMATA. 


I  had  the  opportunity  of  examining  the  progress  of  this  case  very 
carefully  for  a  month  after  the  February  consultation.  The  patient  was 
weak,  debilitated,  and  rendered  almost  hysterically  nervous  from  the 
suffering  during  the  day  by  the  flushing  and  lancinating  pains  and  from 
these  combined  with  headache  at  night.  The  tumors  were  exquisitely 
painful  and  the  slightest  touch  was  dreaded.  It  was  only  after  the 
fourth  day,  during  which  time  the  patient  had  taken  bromide  of  potas- 
sium and  codeia,  that  I  could  make  a  thorough  examination  of  the 
tumors,  and  I  found  from  the  surface  thermometer  a  temperature  of 
98f°  F.  on  the  tumors.  During  this  period  of  illness  she  had  lost  much 
flesh.  As  soon  as  the  pain  had  been  relieved,  the  codeia  was  stopped 
and  the  bromide,  combined  with  the  iodide  of  potassium,  was  given  in 
doses,  beginning  with  thirty  grains  of  the  bromide  and  ten  of  the  iodide, 
three  times  daily.  Besides  this,  forty  grains  of  mercurial  ointment  were 
rubbed  into  the  groins,  armpits,  and  legs  near  the  tumors  daily  for  about 
ten  days.    The  iodide  was  pushed  to  forty  grains,  thrice  daily. 

The  further  history  of  the  tumors  is  interesting  and  peculiar.  The 
rosy  red  deepened  into  a  sombre  red,  and  then  in  the  centre  of  each, 
which  was  slightly  convex,  the  redness  gradually  paled  until  a  color 
similar  to  white  wax  was  left.  The  tumors  then  presented  a  very  strik- 
ing appearance :  about  one-third  of  their  whole  extent  and  sharply 
limited  to  their  centres,  they  were  of  this  waxy  color,  which  wras  sur- 
rounded by  an  areola  of  various  shades,  constituting  a  peculiar  play  of 
colors,  such  as  is  often  seen  in  erythema  nodosum,  and  which  is  admir- 
ably shown  in  plate  No.  3  of  the  late  Tilbury  Fox's  Atlas  of  Skin  Dis- 
eases. The  differences,  though,  if  carefully  studied,  were  well  marked. 
There  was  a  more  aphlegmasic,  indolent,  and  subacute  appearance  to 
the  eruption  of  the  patient.  The  various  shades  of  circumferential  red- 
ness were  more  sombre,  the  tumors  which  then  could  be  examined  were 
more  sharply  circumscribed,  and  there  was  decidedly  less  surface  heat 
than  in  simple  erythema  nodosum.  Yet  I  can  readily  see  how  an  error 
could  have  been  made. 

In  proportion  as  the  bromide  and  iodide  were  pushed  and  the  mer- 
curial inunctions  continued,  the  nutrition  of  the  patient  improved,  the 
appetite  returned,  the  headache  ceased,  and  the  neuralgic  pains  grew 
less,  so  that  on  the  twentieth  day  after  the  institution  of  the  treatment 
the  condition  of  the  patient  was  very  favorable.  The  tumors  slowly 
underwent  absorption.  The  waxy  colored  centre  increased  peripherally 
as  the  variegated  and  sombre  red  areola  grew  less,  until  in  a  month  the 
site  of  the  tumors  showed  only  traces  of  slight  hyperemia.  But  for 
fully  three  weeks  after  the  disappearance  of  the  surface  changes  distinct 
nodules,  non-adherent  to  the  skin  above  and  the  fasciae  beneath,  could 
be  distinctly  felt.  The  subcutaneous  tumors  on  the  thighs  were  aborted 
by  the  treatment.  At  first  the  pain  grew  less  and  soon  their  size 
diminished,  until  in  about  a  month  they  could  be  no  longer  felt. 

The  date  of  invasion  of  this  eruption  was  four  months  after  infection. 

In  the  spring  and  summer  of  the  year  1879,  while  attending  physician 
to  the  class  of  skin  diseases  at  Bellevue  Hospital,  I  had  under  my  care 
a  woman  whose  case  was  to  me  and  to  my  colleague,  the  late  Professor 
Bumstead,  unusual  and  remarkable. 


TAYLOR,  PRECOCIOUS   GU  MM  AT  A.  %  65 

Case  VII. — The  patient  was  a  married  woman,  twenty-five  years  of 
age,  of  dark  complexion,  very  thin  and  sallow,  who  had  long  lived  in 
the  South  and  suffered  from  malaria,  chiefly  in  the  form  of  remittent 
fever  and  neuralgic  pains  in  the  head.  She  had  been  infected  with 
syphilis  in  April  and  had  active  and  extensive  papulo-pustular  eruption, 
double  iritis,  and  nodes  on  the  cranium  and  on  both  ulnse,  near  the  elbow- 
joint.  For  these  she  was  treated  and  was  in  August  free  from  lesions, 
when  she  began  to  complain  of  an  atrocious  nocturnal  cephalalgia. 
This  was  followed  by  pain  in  the  larger  joints  and  a  marked  hyperes- 
thesia in  both  legs.  Coincidently  there  were  malaise,  loss  of  appetite, 
insomnia,  and,  as  she  tersely  described  it,  a  generally  wretched  condi- 
tion. After  three  days  of  this  suffering  she  observed  some  red  patches 
or  swellings  on  the  legs,  chiefly  on  the  middle  and  upper  thirds.  I  saw 
her  two  days  after  the  invasion  of  this  eruption  and  found  her  scarcely 
able  to  walk.  Both  legs  were  swollen,  red,  and  oedematous.  On  each 
were  fully  six  large  plaques  of  infiltrated  skin.  The  color  was  of  a  deep 
red,  the  epidermis  tense  and  shining,  and  slightly  elevated  above  the 
intervening  skin,  which  was  also  oedematous  and  less  red  than  the 
tumors.  There  were  two  large  oval  tumors  on  the  outer  surface  of  the 
thighs.  These  lesions  were  hard  and  firm  to  the  touch  and  so  exquisitely 
sensitive  that  it  was  with  much  difficulty  that  an  examination  could  be 
made.  The  infiltrations  increased  in  extent,  became  more  salient,  while 
the  deep  red  color  became  of  a  bluish-black,  exactly  like  a  severe  con- 
tusion. The  intensity  of  the  discoloration  was  greatest  in  the  centre 
and  shading  off  slightly  toward  the  periphery.  About  fourteen  days 
elapsed  between  the  onset  of  the  skin  lesions  and  their  full  development. 
At  that  time  the  severe  neuralgic  and  rheumatoid  symptoms  were  much 
relieved  and  the  general  condition  of  the  patient  better.  I  was  at  that 
time  disposed  to  attribute  the  relief  of  the  neurotic  condition  to  the 
large  doses  of  bromide  which  were  given,  but  subsequent  observation 
has  shown  me  that  in  some  cases  in  proportion  as  the  eruption  matures 
the  suffering  grows  less.  Mauriac  has  also  observed  this  fact.  A  point 
of  interest  in  this  case  was  that  several  of  the  tumors  so  increased  in  size 
that  they  fused  together  and  resulted  in  patches  of  infiltration  nearly 
six  inches  in  diameter.  Under  the  mixed  treatment  and  soothing  appli- 
cations resolution  took  place  slowly,  except  in  two  of  the  tumors  seated 
on  the  lower  third  of  each  leg,  which  softened  in  the  centre,  ulcerated, 
and  presented  the  characteristics  of  ulcerating  gummata. 

The  period  of  evolution  of  this  eruption  was  about  fourteen  days,  the 
subsequent  stationary  period  was  a  month  for  the  resolutive  tumors  and 
about  two  months  for  the  ulcerative  ones.  The  date  of  evolution  of  the 
eruption  was  four  and  a  half  months.  Very  little  scarring  was  observ- 
able on  the  sites  of  the  ulcers. 

Case  VIII.  was  that  of  a  gentleman  thirty-two  years  old,  who  was 
under  my  care  in  the  summer  of  1885.  He  contracted  syphilis  while 
abroad  and  had  a  small  ephemeral  initial  lesion,  followed  by  very  mild 
secondary  manifestations.  In  the  fifth  month  of  his  syphilis  he  became 
much  worried  by  business  reverses  and  was  forced  to  undergo  severe 
physical  and  mental  strain.  In  this  condition,  being  a  thin,  not  very 
strong  person,  he  began  to  suffer  from  nocturnal  cephalalgia,  intermittent 
neuralgia  of  several  of  the  left  intercostal  and  of  both  anterior  crural 
nerves.  About  a  week  after  the  onset  of  this  neuralgic  condition  ho 
noticed  on  each  leg  a  number  of  bright  red  swellings.    These  increased 

no.  clxxxvii. — july,  1887.  5 


66 


TAYLOR,  PRECOCIOUS  GUMMATA. 


in  size  and  followed  precisely  the  same  course  as  was  observed  in  the 
first  cases.  I  found  the  same  hyper  aesthetic  tumors,  with  a  waxy  look- 
ing centre  and  the  variegated  areola.  Rather  less  than  fourteen  days 
elapsed  from  the  time  of  invasion  to  the  full  development  of  the 
eruption.  He  was  cured  by  local  inunctions  and  iodide  of  potassium 
internally. 

Case  IX.  was  that  of  a  woman  forty-eight  years  of  age,  who  was  of 
robust  build,  but  had  suffered  at  intervals  during  the  last  ten  years  wTith 
rheumatism.  She  was  much  given  to  alcoholic  excess.  Ten  weeks  after 
infection,  which  was  in  December,  1882,  coincidently  with  a  copious 
roseola,  she  w7as  attacked  by  an  eruption  of  round  and  oval  tumors  on 
the  forearms,  legs,  and  hypogastrium.  The  deep  red  color  became 
deeper  until  a  hemorrhagic  appearance  was  presented.  Then  paling 
begun  in  the  centre,  being  first  of  a  bluish-green,  then  dark  green,  then 
of  a  brownish-yellow,  until  entire  resolution  was  effected  in  twTo  months. 

Case  X.  was  also  that  of  a  woman  fifty-three  years  of  age,  seen  by  me 
in  the  fall  of  1884.  She  had  borne  twelve  children  in  fifteen  years  and 
thought  that  the  ill  health  from  which  she  had  suffered  since  she  was  forty 
years  of  age  was  the  result  of  these  frequent  pregnancies.  She  suffered 
also  from  subacute  bronchitis  wThich  had  followed  pneumonia.  Three 
months  after  infection  she  had  a  copious  eruption  of  the  tumors  such  as 
I  have  already  described,  which  were  the  seat  of  neuralgia  and  sur- 
rounded by  hypersesthetic  skin.  Resolution  did  not  take  place,  the 
tumors  softened  and  broke  down  into  typical  gummatous  ulcers,  which 
were  healed  in  three  months,  during  which  time  a  small  crop  of  new 
tumors  developed.    Very  superficial  scars  were  left. 

These  five  cases,  I  think,  may  be  taken  as  typical  illustrations  of  the 
third  form  of  precocious  gummata.  The  date  of  evolution  of  the  erup- 
tion was  respectively  four,  four  and  a  half,  two  and  a  half,  and  three 
months  after  infection,  while  in  Mauriac's  cases  the  eruption  began  at 
two  months  in  three  cases,  four  and  a  half  in  one,  and  at  nine  months  in 
the  fifth.  In  my  cases  it  occurred  in  women  four  times  and  in  men 
once,  while  in  Mauriac's  cases  three  times  in  men  and  twice  in  women. 
In  my  cases  the  ages  of  the  patients  were  thirty-seven,  twrenty-five, 
thirty-two,  forty-eight,  and  fifty-three,  while  those  of  Mauriac  were 
thirty-eight,  forty-seven,  twenty-three,  and  thirty-four.  So  that  in  no 
case  has  it  thus  far  been  found  earlier  than  the  tw7enty-third  year,  nor 
later  than  the  fifty-third. 

The  clinical  history  of  this  form  of  syphilide  has  an  individuality  of  its 
own.  In  the  very  early  months  of  the  diathesis,  either  in  the  stationary 
period  of  an  early  syphilide  or  at  its  decline,  generally  preceded  or  ac- 
companied by  severe  neuralgic  symptoms  involving  the  facial  or  cranial, 
intercostal,  anterior  crural  or,  in  fact,  in  any  cutaneous  nerve,  by  severe 
cephalalgia,  continuous  or  nocturnal;  by  rheumatoid  pains  in  muscles 
or  joints,  and  by  general  malaise  and  debility,  this  eruption  makes  its 
appearance  with  more  or  less  promptitude  and  develops  quite  rapidly. 
In  some  instances  the  invasion  is  very  acute,  so  that  at  the  end  of  a  week 


TAYLOR,  PRECOCIOUS 


GUM  MAT  A. 


67 


we  may  find  fully  developed  tumors  an  inch  or  two  long,  in  others  and  in 
the  majority  of  instances  the  development  is  slower  and  nearly  two  weeks 
elapse.  Besides  the  general  neuralgic  symptoms,  local  pains  on  the  site 
of  the  lesions  or  in  the  whole  territory  on  Avhich  they  are  developed  are 
experienced.  These  may  be  continuous  or  intermittent  and  in  some 
cases  are  as  excruciating  as  in  severe  herpes  zoster.  They  are  described 
as  flashing,  burning,  lancinating,  and  are  sometimes  said  to  resemble 
those  of.  an  abscess.  In  some  instances  the  sufferings  are  less  after  the 
evolution  of  the  syphilide,  but  in  the  majority  of  the  cases  the  tumors 
throughout  their  course  are  the  seat  of  exceeding  hyperesthesia  and 
patients  shrink  with  terror  from  their  palpation.  Besides  these  pheno- 
mena we  generally  find  a  moderate  febrile  movement,  an  evening  tem- 
perature of  100°  or  101°  F.,  and  in  the  very  severe  cases  as  high  as  104° ; 
emaciation,  want  of  appetite,  and  all  their  concomitant  symptoms.  The 
seats  of  predilection  are  the  forearms  and  legs,  but  the  tumors  are  also 
found  on  the  shoulders,  arms,  thighs,  chest,  and  trunk.  As  a  result  of 
the  pain,  swelling,  and  tension,  there  are  more  or  less  discomfort,  stiffness, 
impairment  of  motion,  even  to  the  extent  of  a  pseudo-paralysis  in  the 
arms  and  legs. 

The  eruption  consists  of  two  orders  of  lesions:  first,  tumors  or  nodosi- 
ties seated  in  the  subcutaneous  tissue  and  freely  movable  under  the  skin 
and  over  the  fasciae,,  though  as  they  increase  they  may  contract  adhe- 
sions on  both  surfaces ;  second,  oval  or  round  tumors,  or  irregular 
plaques  from  fusion  of  tumors.  In  my  experience  the  subcutaneous 
nodosities  occur  much  less  frequently  than  the  tumors,  while  Mauriac 
seems  to  regard  them  as  almost  constant  accompaniments  to  the  erup- 
tion. The  tumors  begin  by  infiltration  in  the  deeper  portions  of  the 
skin  and  its  contiguous  connective  tissue.  When  first  seen  they  are  of 
a  bright  red,  rather  sharply  circumscribed,  and  painful.  They  quite 
rapidly  increase  in  size  into  round  or  oval  swellings,  slightly  raised  and 
convex.  In  some  cases  the  bright  red  rapidly  becomes  darkened  until 
a  blackish-red  or  decidedly  ecchymotic  appearance  is  seen,  while  in 
others  it  is  of  a  very  deep  red,  similar  to  what  we  see  in  erythema 
nodosum.  In  some  cases  again  the  red  centre  pales  and  becomes  the 
color  of  white  wax  or  of  a  billiard  ball,  while  the  deep  red  border 
remains  in  various  stages  of  intensity,  consisting  of  a  commingling  or 
play  of  colors  such  as  we  see  following  a  bruise  or  erythema  nodosum. 
In  most  of  the  cases  resolution  takes  place,  and  there  are  but  two  stages  : 
the  first,  that  of  condensation  ;  the  second,  that  in  which  softening  takes 
place,  which  may,  but  does  not  invariably  end  in  resolution.  Mauriac  is 
very  positive  in  his  assertion  that  resolution  always  takes  place.  In 
two  of  my  cases  ulceration  followed  softening,  and  in  a  case  of  Dr. 
Bronson's  I  observed  this  same  result. 

In  my  Case  VII.,  observed  in  1879,  ulceration  took  place  and  its 


68 


TAYLOR,  PRECOCIOUS  GUMMATA. 


occurrence  convinced  my  late  colleague,  Dr.  Bumstead,  who  watched 
the  case  with  me,  that  the  eruption  which  had  so  puzzled  us,  in  which 
we  leaned  to  the  opinion  at  first  that  it  was  a  case  of  intercurrent 
erythema  nodosum,  was  really  a  precocious  and  then  anomalous  form  of 
gummata.  The  ulcerations  which  follow  the  breaking  down  of  these 
tumors  present  all  of  the  characters  of  the  late  gummata,  only  in  a  more 
superficial  degree.  Their  edges  are  usually  not  quite  as  thick  nor  are 
their  floors  as  deep,  but  otherwise  the  appearances  are  the  same  and 
their  subsequent  course  is  usually  aphlegmasic  and  chronic.  In  excep- 
tional cases  general  inflammation  and  swelling  attacks  a  limb  or  limbs 
the  seat  of  these  tumors,  and  the  suffering  is  thereby  intensified.  The 
tumors  are  usually  symmetrically  distributed  and  remain  isolated  with 
little  tendency  to  coalescence.  In  some  cases  after  being  fully  formed 
they  may  take  on  renewed  action,  enlarge,  and  become  fused  together. 

I  was  much  surprised  at  the  cicatrices  following  the  tumors  which 
underwent  degeneration.  The  extent  and  depth  of  the  process  led  me 
to  think  that  much  loss  of  tissue  would  result,  such  as  we  find  in  late 
gummata.  But,  on  the  contrary,  the  resulting  cicatrices  were  com- 
paratively slight  and  it  was  evident  that  great  destruction  of  the  skin 
had  not  occurred. 

In  all  cases  of  precocious  gummata,  the  use  of  iodide  of  potassium  is 
indicated,  either  combined  wTith  a  mercurial  or  with  the  use  of  inunctions 
of  mercurial  ointment. 

Such,  then,  is  a  quite  comprehensive  description  of  an  eruption  which 
Mauriac,  who  is  the  only  author  who  has  previously  described  it,  has 
called  syphilitic  erythema  nodosum.  I  am  utterly  opposed  to  the  names 
of  skin  diseases,  such  as  lichen,  eczema,  psoriasis,  lupus,  etc.,  with  the 
adjective  syphilitic  being  used  to  signify  eruptions  due  to  the  diathesis, 
since  nothing  but  confusion  and  inaccuracy  can  result  from  such  a 
nomenclature.  There  is  every  reason  against  and  none  in.  favor  of 
calling  this  eruption  by  Mauriac's  title.  It  is  a  precocious  gumma 
presenting  certain  resemblances  in  its  mode  of  invasion,  course,  and 
appearances  to  the  erythema  nodosum.  The  clinical  history  of  the 
simple  eruption  is  different  from  that  of  the  specific.  In  the  latter  there 
is  the  history  of  recent  infection,  and  usually  a  coexistence  of  declining 
or  active  syphilitic  manifestation.  The  febrile  symptoms  of  the  early 
gummata  are  usually  not  as  pronounced  as  those  accompanying  the 
simple  eruption,  nor  is  its  invasion  quite  as  sudden  and  rapid  as  in  ery- 
thema nodosum,  it  is  more  aphlegmasic.  In  the  syphilitic  eruption  the 
nervous  symptoms  are  usually  much  more  severe  than  in  the  simple 
form.  Should  doubt  exist  in  the  mind  of  the  observer  early  in  the 
history  of  the  eruption,  as  the  evolution  progresses,  and  with  the  history 
of  the  case  before  him,  with  its  more  chronic  and  aphlegmasic  course, 
and  its  rebelliousness  to  simple  treatment,  it  will  soon  be  dispelled.  The 


CHEYXE,  BACTERIOLOGY. 


69 


fact  that  these  tumors  break  down  and  take  on  the  appearances  and 
run  the  course  of  typical  gummata,  to  my  mind,  proves  beyond  doubt 
their  syphilitic  origin  and  nature. 

The  coincidence  of  erythema  multiforme  with  syphilis  has  been 
observed  by  Danielssen,1  Lipp,2  and  Finger,3  and  has  been  the  subject 
of  a  recent  paper  by  Bronson,4  and  beyond  the  fact  that  in  such  cases 
syphilis  usually  runs  a  severe  course,  as  I  myself  have  observed,  little 
which  is  definite  or  practical  has  been  evolved.  The  consensus  of 
opinion  concerning  this  coincidence  seems  to  be  that  these  symptoms 
are  the  result  of  angio-neuritic  disturbances,  and  though  due  to  some 
occult  influence  of  the  syphilitic  diathesis,  are  not  pathognomonic  of  the 
disease.  Bronson  goes  still  further  in  holding  that,  though  they  may 
begin  as  simple  eruptions,  they  may  later  on  assume  a  true  syphilitic 
nature. 

I  am  firmly  of  the  opinion,  for  reasons  already  given,  that  the  pre- 
cocious neurotic  gummata  are  purely  of  syphilitic  origin  and  nature, 
and  not  in  any  sense  intercurrent  simple  eruptions.  As  in  the  palate, 
throat,  iris,  and  periosteum  there  is  often  precocious  gummatous  infiltra- 
tion, so  in  the  subcutaneous  connective  tissue  of  the  skin,  which  is  essen- 
tially the  one  upon  which  the  activity  of  syphilis  is  spent,  may  this  pre- 
cocious development  take  place.  In  syphilis,  as  in  sarcoma  and  leprosy, 
while  in  general  its  new  growths  are  slow,  aphlegmasic,  localized  and 
chronic,  in  exceptional  cases  they  may  be  precocious,  generalized,  and 
very  active. 

40  West  Twenty-first  Street,  New  York. 


BACTERIOLOGY. 
By  W.  Watson  Cheyne,  M.B.,  F.R.C.S., 

ASSISTANT  SURGEON  TO  KING'S  COLLEGE  HOSPITAL,  LONDON,  EXAMINEE  IN  SURGERY  TO  THE 
UNIVERSITY  OF  EDINBURGH,  ETC. 

(fifth  paper.) 

II.  Study  of  Bacteeia  byt  Means  of  Cultivation. 

The  two  chief  aims  in  carrying  on  cultivations  of  a  definite  species 
of  bacterium  are  in  the  first  place  to  get  it  pure,  and  in  the  second  place 
to  keep  it  pure.  The  methods  of  getting  a  pure  cultivation  and  also  the 
methods  of  keeping  it  pure,  differ  under  different  circumstances,  and, 
therefore,  will  be  best  described  as  occasion  arises;  but  there  are  certain 

1  Norsk  Magaz.  f.  Laegervidsk,  iv.  6.    Two  notes  by  Finger. 

2  Arcbiv  fiir  Dermatologie  mid  Syphilis,  1S71,  vol.  iv.  page  221. 

8  Ueber  den  Zusammenbang  der  multiformen  Erytheme  mit  dem  Syphilis-Processe.     Prager  med. 
Wochenschrift,  1882,  p.  262. 
4  Erythanthema  Syphiliticum.    Medical  Record,  September  4,  1886. 


70 


CHEYNE,  BACTERIOLOGY. 


points  in  connection  with  the  second  aim  which  are  common  to  all  culti- 
vations. As  dust  is  everywhere,  both  floating  in  the  air  and  settled  on 
surrounding  objects,  and  as  dust  contains  large  numbers  of  bacteria  or 
their  spores,  it  follows  that  all  vessels  and  materials  employed  in  the 
cultivation  and  preservation  of  bacteria  are  already  contaminated.  - 
Hence  the  problem  of  keeping  a  cultivation  pure  resolves  itself  into 
two  parts — (a)  the  destruction  of  the  microorganisms  primarily  existing 
in  the  vessels  and  cultivating  materials,  and  (6)  the  prevention  of  access 
of  new  ones.  The  first  thing  that  must  be  done  then,  in  connection 
with  cultivations,  is  to  disinfect  or  sterilize  all  the  vessels  employed,  and 
to  do  this  in  such  a  manner  that  they  cannot  become  reinfected  before 
use.  This  is  done,  for  the  most  part,  by  heat.  It  has  been  found,  experi- 
mentally, that  dry  heat  at  the  temperature  of  from  140°  to  150°  C,  con- 
tinued for  two  to  three  hours,  effectually  destroys  all  bacteria  and  spores. 
Hence  all  tubes,  flasks,  and  glass  vessels  in  general  which  will  afterward 
contain  cultivating  materials,  are  kept  at  this  temperature  for  three 
hours,  and,  as  in  the  case  of  tubes  or  flasks  dust  might  enter  during 
cooling  or  afterward,  their  orifices  are  plugged  firmly  beforehand  with 

Fig.  1. 


Hot  box  containing  a  crate  with  tubes,  and  fitted  with  a  thermometer  and  thermo-regulator. 

cotton-wool.  It  is  best  to  use  absorbent  wool,  because  the  ordinary 
wool  becomes  brown  and  more  brittle  than  the  other.  Various  kinds  of 
apparatus  are  used  for  heating  the  vessels,  of  which  one  is  shown  in  the 
accompanying  sketch  (Fig.  1).  It  consists  of  a  double  walled  vessel, 
the  outer  wall  being  open  at  the  bottom  and  there  being  also  a  hole  at 


CHEYNE,  BACTERIOLOGY. 


71 


the  top.  The  door  is  also  double.  The  gas-flame  plays  over  the  open 
part  at  the  bottom  and  a  current  of  warm  air  circulates  between  the 
walls  so  that  the  interior  is  equally  heated.  At  the  top  a  thermometer 
is  passed  through  a  hole  in  both  walls  into  the  interior  and  there  is  also 
a  place  for  a  thermo-regulator.  The  form  of  apparatus  shown  in  the 
sketch  may  either  stand  on  the  floor  or  be  hung  up  on  the  wall — a  layer 
of  asbestos  paper  intervening  between  it  and  the  wall.  It  is  more  con- 
venient than  the  older  forms,  where  there  was  no  door  outside,  but  where 
the  inside  box  was  enclosed  in  an  outer  iron  cover.  Here  the  door  can 
be  opened  and  apparatus  removed  or  introduced  with  great  ease  and 
without  first  allowing  the  box  to  cool. 

All  the  other  apparatus  which  comes  in  contact  with  the  cultivating 
material,  such  as  inoculating  needles,  pipettes,  etc.,  should  also  be  ster- 
ilized by  dry  heat.  Antiseptic  lotions,  especially  1 : 1000  corrosive  sub- 
limate solution  in  water,  may  be  used  to  purify  the  outside  dishes,  etc., 
in  some  cases,  but  they  must  not  be  employed  for  anything  which  will 
come  in  contact  with  the  cultivating  material,  because  a  very  small 
quantity  of  the  sublimate  will  prevent  growth.  Carbolic  acid  must 
also  be  avoided  unless  it  is  afterward  washed  away,  as  even  the  presence 
of  the  vapor  will  hinder  development. 

There  are  two  classes  of  cultivating  materials  employed,  viz.,  fluids 
and  solids.  The  methods  by  which  these  are  prepared  and  used  differ 
a  great  deal,  and  must  therefore  be  considered  separately. 

1.  Fluid  Cultivating  Media. — A  great  many  fluid  media  have 
been  employed,  of  which  I  need  only  indicate  the  chief  ones.  That  most 
frequently  used  at  the  present  time  is  an  infusion  of  meat.  This  may 
be  prepared  by  cutting  up  a  pound  of  lean  beef  into  small  pieces  and 
placing  it  in  a  vessel  containing  a  litre  of  water.  This  is  set  in  an  ice 
safe  for  twenty-four  hours,  and  then  by  means  of  a  press  all  the  juice 
is  squeezed  out  of  the  meat.  Where  an  ice  safe  and  press  are  not  at 
hand,  it  is  sufficient  to  keep  the  material  simmering  for  two  or  three 
hours.  In  either  case,  the  resulting  fluid  is  boiled  well  so  as  to  pre- 
cipitate the  albumen.  -It  is  then  filtered  and  may  be  at  once  intro- 
duced into  suitable  vessels.  In  this  condition  the  meat  is  acid,  but 
as  an  acid  medium  is  not  a  good  soil  for  many  forms  of  bacteria,  it  is 
often  neutralized  with  carbonate  of  soda.  This  should  be  done  before  it 
is  boiled.  The  infusion  can  be  made  still  more  serviceable  by  adding 
about  one  per  cent,  of  peptone  and  a  little  common  salt  to  it.  Some 
prefer  for  different  purposes  the  flesh  of  other  animals,  such  as  calf, 
sheep,  chicken,  etc.,  but  there  is  not  really  much  advantage  in  the  one 
infusion  over  the  other. 

Various  vegetable  infusions  are  also  very  serviceable.  At  one  time  I 
used  an  infusion  of  cucumber  very  extensively,  and  found  it  an  excellent 
material,  more  especially  for  micrococci.  It  is,  however,  strongly  acid, 
and  must  be  neutralized  when  required  for  many  forms  of  bacilli. 


72 


CHEYNE ,  BACTERIOLOGY. 


Urine  was  at  one  time  a  very  favorite  medium,  but  it  has  fallen  into 
disuse  of  late.  It  may  be  used  unboiled  or  boiled.  Urine,  as  it  exists 
in  the  bladder  of  a  healthy  person,  is  free  from  microorganisms,  and  the 
problem  is  therefore  to  get  it  into  sterilized  vessels  without  contamination. 
This  may  be  done  in  the  following  manner :  The  glans  penis  is  first 
thoroughly  washed  with  5  per  cent,  carbolic  acid  solution,  and  then  with 
1  :  500  corrosive  sublimate  solution.  Not  only  is  the  glans  washed,  but 
the  lips  of  the  urethra  are  everted  and  also  washed.  The  first  few  drops 
passed  are  rejected,  as  they  may  be  mixed  with  the  disinfecting  solutions. 
The  cotton-wool  cap  of  a  sterilized  flask  being  removed,  its  place  is  in- 
stantly taken  by  the  glans  penis,  and  urine  is  passed  into  the  flask.  The 
cap,  which  has  been  held  in  such  a  way  that  the  inner  surface  could  not 
become  infected  with  dust,  is  then  at  once  reapplied,  and  the  vessel  is 
placed  in  an  incubator,  kept  at  the  temperature  of  the  human  body,  in 
order  to  see  if  it  remains  pure.  For  some  reason  which  has  not  yet  been 
worked  out,  unboiled  urine  is  not  a  very  favorable  cultivating  medium ; 
boiled  urine,  on  the  other  hand,  is  much  better.  Hence,  as  a  rule,  when 
urine  is  employed  it  is  boiled,  filtered,  and  then  sterilized  by  heat. 

Cow's  milk  is  also  a  very  excellent  cultivating  fluid.  As  the  milk 
exists  in  the  gland  of  a  healthy  cow,  it  is  free  from  bacteria  and  with 
suitable  precautions  can  be  obtained  pure,  but  the  difficulties  are  great, 
and  boiled  milk  is  quite  as  good  a  cultivating  material.  Fresh  milk 
should  be  employed,  and  must  be  sterilized  by  heat. 

Blood  and  blood  serum  are  also  sometimes  employed.  The  blood  is 
withdrawn  with  precautions  against  contamination.  The  skin  is  thor- 
oughly scrubbed  with  antiseptic  lotions  (carbolic  acid  and  corrosive 
sublimate),  and  is  then  divided  with  a  disinfected  knife — in  fact,  the 
various  steps  of  the  operation  are  performed  antiseptically ;  when  the 
vein  is  exposed  (the  internal  jugular  vein  is  the  best)  a  ligature  is  placed 
loosely  around  it,  a  small  incision  is  made,  and  a  piece  of  glass  tubing, 
sterilized  by  passing  it  through  the  flame,  is  tied  in.  To  the  end  of  the 
glass  a  piece  of  India-rubber  tubing,  which  has  been  boiled,  is  attached, 
and  the  end  of  this  is  passed  into  a  sterilized  flask,  a  mass  of  pure  cotton- 
wool surrounding  it  at  the  neck  of  the  flask.  When  sufficient  blood  has 
been  obtained  the  tube  is  clamped  and  withdrawn  from  the  flask,  and 
the  proper  sterile  cotton-wool  plug  is  applied.  It  is  often  difficult  in 
such  a  case  to  get  a  supply  of  serum.  Sir  Joseph  Lister  observed  that 
when  the  flasks  were  sterilized  by  heat  the  clot  did  not  contract  even 
after  many  weeks,,  and  no  serum  could  be  obtained.  In  order  to  prevent 
this  occurrence  it  is  necessary  to  agitate  the  contents  of  the  flask  for 
some  time,  in  the  same  manner  as  one  whips  blood.  Blood  or  serum 
obtained  in  this  way  is,  contrary  to  expectation,  a  very  bad  cultivating 
medium ;  very  often  it  is  necessary  to  introduce  a  large  number  of  the 
bacteria  before  growth  can  be  obtained.  On  the  other  hand,  if  the  serum 
or  blood  is  diluted  with  water,  growth  occurs  readily  and  luxuriantly. 


CHEYNE,  BACTERIOLOGY. 


73 


The  simplest  way  of  obtaining  serum  is  to  withdraw  it  from  the  body- 
without  taking  all  the  precautions  mentioned  before,  only  taking  care 
not  to  let  in  more  microorganisms  than  is  unavoidable  and  then,  when 
the  serum  has  separated,  to  collect  it  in  sterilized  tubes  and  sterilize  it 
by  repeated  heating  to  a  temperature  short  of  coagulation  (about  60°  C.) 
for  an  hour  a  day  for  five  or  six  days  in  succession. 

At  one  time  artificial  cultivating  materials  were  a  good  deal  employed, 
of  which  the  chief  were  Pasteur's  and  Cobn's  solutions.  These  have 
now  fallen  into  disuse  because  they  are  by  no  means  favorable  cultivating 
media,  only  a  few  species  of  bacteria  growing  in  them  at  all  readily. 

The  composition  of  Pasteur's  solution  was : 

Tartrate  of  ammonia  .  .  •  .  .  .  .1  gramme. 
Candy  sugar  .       .       .       ...       .       .       .10  grammes. 

Ashes  of  yeast  •    .'.       .1  gramme. 

Water  100  c.  cm. 

Cohn  introduced  the  following  modification  of  Mayer's  solution : 

Phosphate  of  potash  0.5  gramme. 

Crystallized  sulphate  of  magnesia        .       .       .0.5  " 

Tribasic  phosphate  of  lime  0.05  " 

Tartrate  of  ammonia  1  " 

Distilled  water  100  c.  cm. 

In  using  these  fluid  cultivations  it  is  often  convenient  to  keep  a  stock 
solution  at  hand.  For  this  purpose  the  flasks  introduced  by  Sir  Joseph 
Lister  are  very  convenient  (Fig.  2).    These  flasks  have  two  necks,  a 


Lister's  flask  for  preserving  cultivating  materials.    0,  the  narrow  neck.    P,  the  cotton-wool  cap. 


large  vertical  one  and  a  lateral  one,  which  is  a  bent  spout,  large  at  its 
commencement  and  comparatively  narrow  at  its  shorter  terminal  part 
beyond  the  bend,  O.  The  large  size  of  the  first  part  of  the  neck 
prevents  it  acting  as  a  siphon,  and  the  result  is  that  when  liquid  is 


Fig.  2. 


74  CHEYNE,  BACTERIOLOGY. 

poured  from  such  a  flask,  and  the  vessel  is  afterward  restored  to  the 
erect  position,  the  end  of  the  nozzle  remains  filled  with  a  drop  of  the 
liquid,  and  this  guards  the  orifice  so  that  regurgitation  of  air  can  never 
take  place  through  the  nozzle.  Before  sterilizing  these  flasks  a  cap  of 
cotton- wool  is  tied  over  each  orifice  so  as  to  prevent  the  entrance  of  dust. 
In  filling  these  flasks  (Fig.  3)  it  is  best  to  introduce  the  fluid  into  them 


Fig.  3. 


Method  of  filling  a  Lister's  flask  (see  description). 


by  means  of  a  siphon  (U),  consisting  of  two  glass  tubes  connected  by 
two  pieces  of  India-rubber  tubing  with  an  intervening  stop-cock  (V). 
The  siphon  is  first  completely  filled  with  water,  and  then  one  leg  (S)  is 
placed  in  the  vessel  containing  the  filtered  cultivating  material  (W), 
and  the  tap  is  turned  so  as  to  run  off  the  water  and  replace  it  with  this 
fluid.  The  stop-cock  is  then  shut,  a  piece  of  carbolized  rag  is  wrapped 
around  the  lower  extremity  of  the  free  tube  and  applied  to  the  mouth 
of  the  flask  as  soon  as  the  cotton  cap  is  removed ;  the  tube  (T)  is  then 
pushed  steadily  down  to  the  bottom  of  the  flask  (X),  through  the  car- 
bolized rag  (Y),  the  stop-cock  turned,  and  the  required  amount  of  fluid 
introduced.  When  this  has  been  done  the  tap  is  again  turned  off,  the 
siphon  withdrawn  through  the  antiseptic  rag,  and  a  fresh  cap  of  steril- 
ized cotton-wool  is  tied  over  the  mouth  of  the  flask  when  the  carbolized 
rag  is  removed.  The  fluid  is  then  sterilized  and  can  be  kept  for  any 
length  of  time.    A  portion  of  the  fluid  can  be  poured  out  of  the  flask 


CHEYNE,  BACTERIOLOGY. 


75 


into  smaller  vessels  from  time  to  time  without  injury  to  the  stock  solution. 
To  do  this  the  cotton  cap  is  removed  from  the  nozzle  of  the  flask,  and  the 
end  of  this  is  instantly  slipped  through  an  opening  in  the  centre  of  half 
an  India-rubber  ball  which  has  been  previously  sterilized  (Fig.  4,  R).  The 
protecting  plug  or  cap  having  been  removed  from  the  vessel  to  be  filled, 
the  India-rubber  cap  instantly  takes  its  place,  thus  preventing  all  en- 
trance of  dust,  and  the  requisite  amount  of  fluid  is  poured  into  it.  When 
this  is  done,  the  sterile  plug  is  again  inserted  into  the  newly  filled  vessel. 
The  India-rubber  ball  is  then  removed  from  the  flask,  the  drop  of  fluid 


Fig.  4.  Yig.  5. 


Method  of  filling  vessels  from  a  Lister's  flask.  Erlenmeyer's  flask. 

R,  half  an  India-rubber  ball  through  which 
the  nozzle  is  passed. 

which  remains  in  the  nozzle  sucked  away  with  a  carbolized  rag,  and  a 
fresh  sterilized  cotton  cap  is  applied.  With  a  little  practice  these  mani- 
pulations can  be  carried  out  in  such  a  way  that  neither  the  fluid  in  the 
stock  solution  nor  that  in  the  newly  filled  vessel  is  contaminated ;  but  it  is 
well  to  make  quite  sure  of  this  by  sterilizing  both  again.  If  it  is  neces- 
sary to  know  exactly  the  quantity  of  fluid  in  the  flask  or  tube,  it  must 
be  filled  by  means  of  a  graduated  pipette  or  burette. 

For  cultivating  purposes  the  vessels  generally  used  are  test  tubes  or 
flasks,  the  form  known  as  the  Erlenmeyer  flask  (Fig.  5)  being  the  best. 
The  necks  of  the  tubes  and  flasks  are  generally  tightly  plugged  with 
cotton-wool  before  they  are  sterilized  in  the  hot  box.  The  objections 
which  I  have  to  this  method  are  that  dust  collects  on  the  top  of  the  wool 
and  in  pulling  out  the  plugs  some  particles  may  fall  into  the  interior. 
The  danger  of  contamination  can  generally  be  avoided  by  igniting  the 
top  of  the  plug  before  it  is  removed,  thus  destroying  any  living  germs 
which  may  be  present  in  it.  But  particles  of  dust  may  have  passed 
down  for  some  distance  between  the  wool  and  the  glass,  and  may  escape 
destruction.  This  is  not  of  so  much  moment  where  the  cultivations  are 
solid,  because  the  vessels  may  be  held  very  obliquely  or  even  upside 
down,  but  where  fluids  are  used  it  is  not  so  easy  to  prevent  their  admis- 
sion. For  this  reason,  when  I  use  fluids  I  generally  employ  flasks  and 
not  test  tubes,  and  instead  of  plugging  their  necks  I  tie  the  wool  ever 


76 


CHEYNE,  BACTERIOLOGY. 


Fig.  6. 


Flask  with  cotton-wool 
cap  containing  cultivating 
fluid  inoculated  by  means 
of  a  capillary  tube. 


the  orifice,  and,  as  after  sterilization  the  wool  is  more  powdery,  I  enclose 
the  mass  of  wool  in  a  double  piece  of  gauze  (Fig.  6,  A).  The  mass  is 
bent  over  the  mouth  of  the  flask  and  secured  round 
the  neck  by  copper  wire.  Before  opening  the  flask 
I  wet  the  edge  of  the  wool  all  round  with  carbolic 
lotion  and  also  moisten  its  whole  surface.  Thus, 
even  though  the  carbolic  acid  may  not  have  de- 
stroyed the  spores  on  the  wool,  the  moisture  fixes 
them  so  that  they  do  not  fly  about  when  the  wool 
is  lifted.  Another  advantage  of  this  arrangement 
is  that  the  wool  need  not  be  completely  removed 
from  the  orifice  of  the  flask,  but  one  side  may  be 
lifted  and  any  instrument  slipped  into  the  flask 
under  cover  of  the  cap. 

The  culture  fluids  having  been  thus  prepared, 
filtered,  and  introduced  either  into  the  stock  flask, 
or  into  the  smaller  flasks,  must  be  sterilized  because, 
during  filtration  and  the  other  manipulations,  they  have  become  con- 
taminated from  the  air  and  surrounding  objects.  This  sterilization  is 
best  effected  by  means  of  Koch's  steaming  apparatus  (Fig.  7).  This  is 
a  deep  iron  or  tin  vessel  in  the  bottom  of  which  water  is  placed,  and 
just  above  the  water  is  a  tray  on  which  flasks, 
etc.,  can  stand.  The  lid  fits  loosely  and  both  the 
lid  and  the  vessel  itself  are  surrounded  with  felt. 
The  water  in  the  interior  is  boiled  till  steam 
issues  from  the  top,  and  till  the  thermometer 
passed  through  the  lid  indicates  almost  100°  C. 
The  vessels  containing  the  culture  fluid  are  then 
introduced  and  allowed  to  remain  for  from  half 
an  hour  to  an  hour.  The  result  is  that  all  bacteria 
not  in  the  spore  state  are  killed.  Following 
Tyndall's  experiments  the  flasks  are  then  set 
aside  in  a  moderately  warm  place  for  twenty -four 
hours.  By  that  time  spores,  if  present,  will 
probably  have  sprouted  and,  therefore,  the  steam- 
ing process  is  repeated.  To  make  the  steriliza- 
tion quite  certain,  another  twenty-four  hours  are 
allowed  to  elapse  and  again  the  flasks  are  heated. 
The  result  of  this  is  that  one  may  reckon  with 
certainty  that  all  bacteria  present  in  the  fluid 
are  destroyed.  This  is  a  much  better  way  of 
proceeding  than  the  old  plan  of  boiling  the  fluid, 
because  in  boiling  the  fluid  a  large  amount  of 
evaporation  occurs,  and  its  constitution  is,  therefore,  altered,  and  also  if 
any  portions  of  the  original  impure  fluid  have  remained  at  the  top  of 


Fig.  7. 


Koch's  steaming  apparatus 
for  sterilizing  culture  mate- 
rials. 


CHEYNE,  BACTERIOLOGY. 


77 


the  flask,  or  been  splashed  up  during  the  bubbling,  they  may  not  be 
sufficiently  heated  and  may  afterward  contaminate  the  mass.  On  the 
other  hand,  in  the  steaming  apparatus  the  whole  flask  is  equally  heated 
and  sterilized.  Indeed,  with  such  fluids  as  milk  this  is  the  only  possible 
way  of  sterilizing  them,  because  on  attempting  to  boil  milk  a  scum  forms 
on  the  surface  and  the  milk  either  boils  over  or  is  imperfectly  sterilized. 

In  the  case  of  blood  serum,  as  has  already  been  said,  the  temperature 
should  not  be  raised  above  60°  C,  for  coagulation  occurs  at  65°  C.  It 
has  been  found,  however,  that  an  hour's  exposure  to  60°  C.  is  sufficient 
to  kill  almost  all  adult  bacteria,  and  one  may  reckon  that  if  this  process 
is  repeated  for,  say,  five  or  six  days  in  succession,  the  serum  will  be  com- 
pletely sterilized. 

After  the  process  of  sterilization  is  complete  the  vessels  should  be 
placed  for  three  or  four  days  before  use  in  an  incubator  kept  at  the 
temperature  of  the  human  body,  in  order  to  be  certain  that  the  material 
is  thoroughly  sterile. 

These  flasks  may  be  inoculated  in  various  ways,  but  more  care  is 
requisite  than  in  the  case  of  solid  cultures,  and  a  number  of  flasks  must 
be  inoculated  at  the  same  time  in  order  to  guard  against  error.  The 
same  method  may  be  employed  as  in  the  case  of  cultures  on  solid  media, 
viz.,  a  piece  of  thin  platinum  wire  is  fixed  in  the  end  of  a  glass  rod — 
a  thing  easily  done  by  heating  both  in  a  Bunsen  flame  and  then  pushing 
the  wire  into  the  soft  glass  —and  this  wire  being  heated  and  allowed  to 
cool  is  dipped  in  the  material  to  be  tested  and  then  introduced  into  the 
fluid  under  cover  of  the  cotton-wool  cap.  This  can  be  rapidly  done,  as  a 
mere  touch  is  sufficient  to  infect  the  fluid. 

In  my  early  experiments  with  discharges  from  wounds1  I  employed 
the  following  plan  with  complete  success.  Small  capillary  tubes,  those 
used  for  vaccination  for  example,  are  passed  through  the  flame  several 
times  to  sterilize  them.  The  end  is  then  applied  to  the  wound  and  at 
once  a  small  quantity  of  the  discharge  runs  up  into  the  tube.  The  edge 
of  the  cotton-wool  cap  being  now  lifted,  the  tube  is  then  dropped  into 
the  flask  and  the  cap  reapplied  (see  Fig.  6). 

Another  plan  which  I  employed  when  inoculating  a  second  flask  from 
the  first,  was  to  use  a  piece  of  glass  tubing  bent  at  right  angles  and 
attached  by  means  of  a  small  bit  of  India-rubber  tubing  to  a  small 
brass  syringe,  the  piston  of  which  had  a  ring  at  the  end.  The  cap  of 
the  first  flask  being  slightly  raised  at  one  side,  the  tube,  previously  heated 
in  the  flame  and  allowed  to  cool,  was  introduced  into  the  flask,  a  small 
quantity  sucked  up  by  withdrawing  the  piston  slightly  by  means  of  the 
little  finger  passed  through  the  loop  and  then  the  cap  of  the  second  flask 
being  lifted  a  drop  was  expelled  into  it.    With  a  little  practice  this 


1  Antiseptic  Surgery,  p.  230. 


78 


CHEYNE,  BACTERIOLOGY. 


manipulation  can  be  performed  rapidly  and  safely.  By  the  same 
manoeuvre  small  quantities  can  be  withdrawn  for  microscopical  examina- 
tion as  before  described. 

The  above  methods  are  what  I  have  found  quite  sufficient  to  enable 
me  to  carry  on  cultivations  in  fluids  with  great  ease  and  certainty, 
but  numerous  other  plans  have  been  described.  Pasteur  employs  a 
number  of  peculiar  shaped  flasks  for  the  preservation  of  fluids,  but  as 
these  have  no  advantage  over  the  Lister  flasks,  and  are  more  complicated, 
I  need  not  mention  them.  The  flasks  which  he  uses  for  cultivations  are, 
however,  very  simple  (Fig.  8).  The  outside  of  the  necks  of  these  flasks 
is  ground,  and  over  this  a  glass  cap  (A),  ground  inside,  fits  tightly,  and 
the  upper  part  of  this  cap,  which  is  narrowed,  is  plugged  with  wool, 
asbestos,  etc.  The  cap  is  lifted  for  purposes  of  inoculation,  examina- 
tion, etc. 

Sternberg  describes  his  method  as  follows  :l  "  The  culture  flasks 
employed  contain  from  one  to  four  fluid-drachms.    They  are  made  from 


Fig.  8.  Fig.  9. 


Pasteur's  cultivating  lia&ks.    A,  glass  cap.  Sternberg's  bulb  containing  culture 

(After  Hueppe.)  fluid,  and  ready  for  use. 

glass  tubing  three-  or  four-tenths  inch  diameter,  and  those  which  the 
writer  has  used  in  his  numerous  experiments  have  all  been  home-made. 
It  is  easier  to  make  new  flasks  than  to  clean  old  ones,  and  they  are 
thrown  away  after  being  once  used.  Bellows,  operated  by  the  foot,  and 
a  flame  of  considerable  size — gas  is  preferable — will  be  required  by 
one  who  proposes  to  construct  these  little  flasks  for  himself.  After  a 
little  practice,  they  are  rapidly  made;  but  as  a  large  number  are 
required,  the  time  and  labor  expended  on  their  preparation  is  no  light 
matter.  After  blowing  a  bulb  at  the  extremity  of  a  long  glass  tube  of 
the  diameter  mentioned,  this  is  provided  with  a  slender  neck,  drawn  out 
in  the  flame,  and  the  end  of  this  is  hermetically  sealed  (Fig.  9).  Thus 

Magnin  and  Sternberg  :  Bacteria,  p.  176.    Wood  &  Co.,  Xew  York,  1884. 


CHEYNE,  BACTEEIOLOGY. 


79 


one  little  flask  after  another  is  made  from  the  same  piece  of  tubing,  until 
this  becomes  too  short  for  further  use.  To  introduce  a  culture  liquid 
into  one  of  the  little  flasks,  heat  the  bulb  slightly,  break  off  the  sealed 
extremity  of  the  tube,  and  plunge  it  beneath  the  surface  of  the  liquid 
(Fig.  10).  The  quantity  which  enters  will,  of  course,  depend  upon  the 
heat  employed,  and  the  consequent  rarefaction  of  the  enclosed  air. 
Ordinarily  the  bulb  is  filled  to  about  one-third  of  its  capacity  with  the  cul- 
ture-liquid, leaving  it  two-thirds  full  of  air  for  the  use  of  the  microscopic 
plants  which  are  to  be  cultivated  in  it."  These  fluids  are  then  sterilized 
by  the  usual  methods,  and  the  flasks  are  kept  in  an  incubator  for  several 
days,  to  make  sure  that  they  are  pure.  "  To  inoculate  the  liquid  con- 
tained in  one  of  these  little  flasks  with  organisms  from  any  source,  the 
end  of  the  tube  is  first  heated  to  destroy  germs  attached  to  the  exterior ; 
the  extremity  is  then  broken  off  with  sterilized — by  heat — forceps ;  the 
bulb  is  very  gently  warmed,  so  as  to  force  out  a  little  air,  and  the  open 
extremity  is  plunged  into  the  liquid  containing  the  organism  to  be  culti- 
vated.   The  smallest  quantity  of  this  is  sufficient,  and  as  soon  as  the 


Fig.  10. 


Method  of  filling  Sternberg's  bulbs  with 
culture  fluid. 


Fig.  11. 


Apparatus  employed  by  Sir  Joseph  Lister  in 
his  experiments  on  lactic  fermeutation.  A, 
liqueur  glass.  B,  small  glass  cap.  C,  large 
glass  shade  covering  the  whole". 


inoculation  is  effected,  the  end  of  the  tube  is  again  sealed  in  the  flame  of 
an  alcohol  lamp.  A  little  experience  will  enable  the  operator  to  inocu- 
late one  tube  from  another  ;  to  introduce  a  minute  quantity  of  blood 
containing  organisms  directly  from  the  veins  of  a  living  animal ;  to 
withdraw  a  small  quantity  of  fluid  from  the  flask  for  microscopical 
examination,  etc.,  without  any  danger  of  contamination  by  atmospheric 
germs." 

Sir  Joseph  Lister,  in  his  experiments  on  lactic  fermentation,  employed 
a  liqueur  glass  (Fig.  11,  A)  covered  by  a  glass  cap  (B),  both  being  covered 
by  a  glass  shade  (C),  the  glass  and  the  shade  standing  on  a  glass  plate. 


80 


CHETNE,  BACTERIOLOGY. 


The  shade  is  removed,  and  the  glass  cap  being  lifted  for  a  moment,  the 
contents  of  the  glass  can  be  readily  inoculated. 

Fluid  cultivation  materials  possess  advantages  in  special  cases,  though 
for  most  purposes  they  have  now  given  place  to  solids.  One  advantage 
which  they  have  over  certain  solids  is  that  they  can  always  be  placed  in  an 
incubator  at  the  temperature  of  the  human  body  without  the  result  being 
in  any  way  spoilt,  whereas  with  certain  solid  media,  such  as  gelatinized 
media,  this  cannot  be  done.  In  experiments  on  the  growth  of  bacteria 
in  different  gases,  fluid  media  are  especially  useful,  and  it  is  by  no  means 
easy  with  solids  to  insure  that  all  the  air  is  displaced  by  the  gas  to  be 
tested.  In  my  report  on  micrococci  in  relation  to  wounds,  abscesses,  and 
septic  processes,1  I  described  a  very  simple  and  efficient  plan  which  I 
had  devised  for  this  purpose.  Into  the  bottom  of  a  glass  bulb  capable 
of  containing  about  one  ounce  of  fluid,  and  having  a  neck  six  inches 
long  and  about  half  an  inch  in  diameter,  is  sealed  the  end  of  a  long, 
narrow  tube,  which  is  bent  up  round  the  side  to  the  top  of  the  bulb,  and 


Fig.  12. 


Bulb  for  testing  the  influence  of  various  gases  on  the  growth  of  bacteria. 

then  runs  out  for  about  four  inches  in  a  horizontal  direction.  The  end 
of  this  tube  is  well  plugged  with  cotton-wool,  a  cotton- wool  cap  is  tied 
round  the  opening  of  the  neck,  and  the  whole  apparatus  is  sterilized  in 
the  hot  box  (Fig.  12).  The  purified  infusion  is  then  introduced  with 
the  usual  precautions  into  the  bulb,  so  as  to  fill  about  one-third  of  it,  the 
cap  reapplied,  and  the  infusion  sterilized  again  in  the  steaming  apparatus, 
if  necessary.  The  bulb  is  then  placed  in  the  incubator  for  some  days  to 
make  sure  that  the  fluid  is  sterile.  When  the  experiment  is  to  be  per- 
formed the  cap  is  lifted,  the  fluid  inoculated  with  the  bacteria  in  the 

i  British  Medical  Journal,  September  and  October  1884. 


CHEYNE,  BACTERIOLOGY. 


81 


manner  formerly  described  for  flasks,  the  cap  reapplied,  and  the  neck 
bent  to  a  right  angle  and  drawn  out  fine,  so  as  to  be  ready  for  rapid 
sealing.  The  end  of  the  other  tube  is  then  connected  with  the  apparatus 
for  generating  and  washing  the  gas,  and  the  gas  is  passed  through  the 

Fig.  13. 


Fig.  14. 


To  show  the  method  of  passing  the  gas  to  be  tested  through  the  inoculated  bulb. 
A,  the  gas  generator.    B,  wash  bottle.    C,  bulb  containing  the  inoculated  fluid. 

fluid  until  the  latter  is  thoroughly  impregnated  with  it,  and  the  air  in 
the  bulb  has  been  entirely  displaced  (Fig.  13).  The  time  required 
varies  with  the  rapidity  of  the  flow  of  the 
gas,  but  ten  minutes  are,  as  a  rule,  amply  suffi- 
cient. The  flow  of  gas  is  now  stopped,  and 
the  neck  and  the  small  tube  sealed  in  the 
flame  of  a  spirit  lamp  (Fig.  14).  Thus  there 
is  only  the  gas  to  be  tested  in  contact  wdth 
the  fluid,  and  no  possibility  of  entrance  of 
other  gases  from  without.  The  apparatus 
can  now  be  placed  in  an  incubator. 

Another  purpose,  for  which  fluid  media  is 
employed,  is  for  drop  cultures.  (See  under 
"Microscopical  Examination  of  Unstained 
Specimens.")  Cupped  slides  are  cleansed 
and  passed  through  the  flame,  or  heated  in 

the  hot  box,  in  a  beaker  plugged  with  cotton-wool.  At  the  same  time, 
thin  cover-glasses  are  heated  by  passing  them  several  times  through  a 
gas-flame,  and  are  then  laid  on  a  glass  plate,  and  allowed  to  cool  under 
cover  from  dust.  A  small  drop  of  the  culture  fluid  is  then  placed  on 
the  centre  of  the  glass,  and  inoculated  with  the  material  to  be  studied. 
A  little  vaseline  is  put  round  the  margin  of  the  cell,  the  slide  inverted 
and  pressed  down  on  the  cover-glass,  so  that  the  drop  is  opposite  the 
centre  of  the  coil,  and  the  slide  then  rapidly  turned  upward.  These 
drop  cultures  are  very  convenient  for  observing  the  movement  and 
growth  of  bacteria,  and  for  the  latter  purpose,  and  for  the  study  of  spore 
formation  and  sprouting  of  spores,  I  have  used  them  extensively.  The 

NO.  CLXXXVII.—  JULY,  1887.  6 


Bulb  with  both  ends  sealed  after 
the  gas  has  been  passed  through  it. 


82 


CHE  YN  E ,  BACTEEIOLOGY. 


sprouting  of  spores 1  may  be  readily  followed  by  inoculating  a  number 
of  these  cupped  slides  with  spore-bearing  material,  and  placing  them  in 
an  incubator.  Remove  one  at  stated  intervals  (say,  one  hour,  one  and  a 
half  hours,  two  hours,  etc.),  lift  up  the  cover-glass,  turn  it  over,  and.dry 
the  drop  of  fluid.  When  dry  wipe  off  the  vaseline  from  the  margin  of 
the  glass,  and  stain  in  a  suitable  material.  In  this  way,  a  series  of 
preparations  can  be  obtained,  showing  all  the  successive  stages  in  the 
sprouting  of  spores.  In  the  same  manner,  the  cycle  of  growth  of  an 
adult  organism  can  also  be  studied,  but,  in  order  to  get  a  series  of 
specimens  showing  accurately  the  successive  changes,  it  is  necessary  to 
have  the  same  proportion  of  bacteria  to  the  fluid  in  each  specimen, 
otherwise  a  specimen  with  many  bacteria,  and  but  little  fluid,  may  show 
more  advanced  changes,  especially  in  the  matter  of  spore-formation, 
after  the  same  length  of  time  than  a  specimen  with  a  smaller  proportion 
of  bacteria  to  the  fluid.  This  is  easily  managed  by  inoculating  a  flask 
of  fluid  with  the  bacteria  to  be  studied,  placing  it  for  a  few  hours  in  an 
incubator,  and  shaking  it  well  before  taking  the  drops  from  it.  The 
bacteria  will  thus  be  equally  distributed  through  the  fluid,  and  a  fairly 
accurate  series  of  specimens  can  be  obtained. 

As  has  just  been  said,  fluid  cultivations  have  dropped  greatly  into 
disuse  of  late,  on  account  of  very  serious  disadvantages  which  they 
possess,  and  on  account  of  the  many  advantages  obtained  by  the  employ- 
ment of  solid  culture  media.  The  two  great  disadvantages  of  fluid 
media  are,  that  if  they  become  contaminated,  the  cultivation  is  spoilt, 
because  the  newcomers  mix  thoroughly  with  the  original  bacteria,  so 
that  further  inoculations  from  such  flasks  simply  carry  over  the  two 
kinds.  The  second  disadvantage  is,  that  the  original  culture  must  be 
started  from  a  material  containing  only  one  kind  of  bacterium,  for  it  is 
extremely  difficult  with  fluid  media  to  separate  one  form  from  another. 
This  separation  has  been  attempted  in  various  ways,  but  these  are  far  too 
difficult,  and  require  too  much  time  to  render  them  practically  useful. 

The  old  plan  was,  to  arrange  the  composition  of  the  cultivating  mate- 
rial, so  that  it  was  more  suitable  for  the  growth  of  the  desired  species 
than  for  other  species.  Then,  by  fresh  inoculations  daily,  as  small  a 
portion  as  possible  of  the  inoculating  material  being  taken,  it  was  hoped 
that  the  desired  species  would  gain  the  upper  hand,  and  ultimately  be 
obtained  pure.    This  hope  was,  however,  but  rarely  realized. 

The  best  method  was  that  used  by  Sir  J oseph  Lister  in  his  experi- 
ments on  lactic  fermentation,  and  proposed  also  independently  by  Nageli 
about  the  same  time.  A  series  of  flasks  of  milk  were  prepared  and  ster- 
ilized. The  milk  containing  the  Bacterium  ladis,  along  with  other  bac- 
teria, was  then  taken  and  an  attempt  made  to  estimate  the  number  of 
bacteria  in  each  drop.    This  was  done  by  placing  one-fiftieth  of  a  minim 

i  See  paper  on  Bacillus  Alvei.    Journal  of  Koyal  Microscopical  Society,  August,  1885. 


CHEYNE,  BACTERIOLOGY. 


83 


on  a  cover-glass  of  such  a  size  that  when  pressed  down  on  the  slide  the 
drop  occupied  exactly  the  area  of  the  cover-glass.  The  number  of  bac- 
teria in  this  quantity  was  next  calculated,  and  then  the  milk  was  diluted 
with  boiled  water  to  such  an  extent  that  every  hundredth  of  a  miuim 
was  estimated  to  contain  one  bacterium.  To  each  of  the  glasses  contain- 
ing the  pure  milk  one-one-hundredth  of  a  minim  of  the  diluted  fluid 
was  then  added  and  the  result  was,  that  in  a  certain  number  a  pure  cul- 
tivation of  Bacterium  lactis  was  obtained. 

2.  Solid  Cultivating  Media. — If  a  boiled  potato  is  sliced  and  exposed 
to  the  air,  it  will  be  seen  in  a  few  days  that  the  surface  of  the  potato  is 
dotted  over  with  spots  of  various  sizes,  some  colored,  some  white,  some 
slimy,  some  dry,  etc.  These  spots  are  groups  or  colonies  of  various 
microorganisms,  and  each  has  developed  from  one  or  a  clump  of  indi- 
viduals which  has  fallen  on  it  from  the  air.  In  the  early  stage,  while 
these  colonies  are  yet  small,  most  of  them  are  isolated,  so  that  each  of 
them  generally  represents  a  pure  cultivation  of  one  or  other  form  of 
microorganism.  If  now  a  small  portion  of  one  of  these  colonies  is  trans- 
ferred to  a  fresh  potato  by  means  of  a  heated  knife  or  needle,  and  the 
potato  kept  in  a  moist  chamber  and  protected  from  dust,  a  pure  culti- 
vation of  the  organism  is  obtained.  Should  any  stray  organisms  fall  on 
the  surface  of  the  potato  during  the  procedure,  they  develop  and  form 
colonies  where  they  fell,  and,  therefore,  do  not  necessarily  vitiate  the 
whole  of  the  original  culture,  portions  of  which  can  be  found  which  are 
pure  and  from  which  fresh  cultures  can  be  made.  One  very  great  advant- 
age of  cultivations  on  solid  media  over  cultivations  in  fluids  is  thus 
at  once  evident,  viz.,  that  while  the  entrance  of  an  accidental  impurity 
entirely  vitiates  a  fluid  culture,  it  does  not  necessarily  spoil  one  on  a 
solid  medium.  Potato  has  been  used  as  a  culture  medium  by  several 
investigators  (e.  g.  Schroeter),  before  Koch's  time,  and  Brefeld  and  Klebs 
also  employed  gelatinized  materials,  but  this  was  with  the  view  of  pre- 
venting evaporation,  and  also  of  enabling  one  to  turn  cultures  on  glass 
slides  upside  down  so  as  to  prevent  dust  falling  on  them.  It  was  Koch 
who  first  recognized  the  value  of  solid  media  in  enabling  the  investigator 
to  get  and  to  keep  cultures  pure,  and  in  his  hands  the  methods  have  been 
elaborated  and  simplified  so  that  they  are  now  universally  adopted.  In 
order  to  obtain  a  transparent  solid  culture  medium,  Koch  employs  in- 
fusions solidified  by  the  addition  of  gelatine,  agar-agar,  etc.  These 
gelatinized  materials  have  turned  out  to  possess  other  great  advantages 
besides  those  of  enabling  one  to  get  and  to  keep  a  cultivation  pure.  It 
is  found  that  the  shape  and  mode  of  spread  of  the  colonies  vary  in  dif- 
ferent kinds  of  bacteria  which  may  be  microscopically  similar,  thai  one 
spreads  only  on  the  surface,  another  only  in  the  interior  of  the  jelly,  one 
renders  the  gelatine  liquid,  another  leaves  it  solid,  etc.  To  such  an  ex- 
tent are  these  peculiarities  distinctive  that  in  several  instances  the  diag- 


84 


CHEYNE,  BACTERIOLOGY. 


nosis  between  two  organisms  is  made  almost  entirely  by  their  behavior 
in  jelly  cultivations  rather  than  by  their  microscopical  appearance,  and 
in  all  cases  attention  must  be  paid  to  their  behavior  on  cultivation  in 
various  media,  and  to  their  other  characteristics  as  well  as  to  the  micro- 
scopical appearances,  before  deciding  as  to  the  species  of  bacterium  under 
observation.  I  shall  now  describe  the  mode  of  preparation  and  use  of 
the  materials  most  frequently  employed. 

a.  Potato.  For  potato  cultivations  ripe  potatoes  are  best,  the  small 
new  potato  not  being  nearly  such  a  good  medium.  As  the  earth  on  the 
outside  of  the  potato  is  full  of  bacteria  and  spores,  it  must  be  washed  off 
as  much  as  possible  and  the  eyes  of  the  potato  cleaned  out.  The  potato 
is  then  laid  in  a  1  to  1000  watery  solution  of  corrosive  sublimate  for 
about  an  hour.  Afterward  it  is  washed  in  water  and  placed  in  the 
steaming  apparatus  and  kept  at  the  temperature  of  100°  C.  for  a  half  to 
three-quarters  of  an  hour.  It  is  then  allowed  to  cool  under  cover  from 
dust.    In  the  meantime  a  couple  of  glass  dishes,  one  larger  than  the 

other  so  as  to  form  a  cover,  are  washed  out  with 
Fig.  15.  1:1000  sublimate  solution,  and  a  piece  of  filter 

paper  moistened  with  the  same  solution  is  placed 
on  the  bottom  of  each,  so  that  when  the  one  is  in- 
verted over  the  other  there  is  a  moist  surface  at 
the  upper  and  lower  part  of  the  chamber.1  This 
a  pair  of  glass  dishes  form-  is  to  keep  the  air  moist  so  that  the  surface  of  the 
ing  a  moist  chamber  and  used  potato  does  not  dry.  The  potato  after  being  cooked 

for  potato,  plate  cultivations.         ,         -■    ,  .         ,  •    ,     .        ii         •      ,i       n  n 

etc  and  cooled  is  cut  into  two  halves  m  the  following 

manner:  A  long  flat  knife  is  heated  in  the  flame 
and  allowed  to  cool.  The  left  hand  is  then  dipped  into  1:1000  sub- 
limate solution  and  the  potato  is  taken  up  with  it.  With  the  knife 
held  in  the  right  hand  a  single  sweep  is  made  through  the  potato,  and 
the  cover  of  the  moist  chamber  being  lifted,  the  two  halves  are  separated 
and  laid  down  with  the  cut  surfaces  uppermost.  The  cover  is  then  re- 
placed and  the  potato  is  ready  for  inoculation.  In  some  cases,  where 
the  potato  is  to  be  placed  at  the  body  temperature  and  kept  for  some 
time,  tall  narrow  vessels  similar  to  those  used  by  Koch  for  testing 
air  (Fig.  26),  plugged  with  cotton-wool  and  sterilized,  and  large  enough 
to  hold  half  a  potato,  are  employed. 

The  surface  of  the  potato  may  be  inoculated  by  the  platinum  wire 
before  described,  or  by  a  thin,  flat  knife,  by  means  of  which  the  material 
is  rubbed  over  the  surface  of  the  potato.  The  knife  or  needle  is  dipped 
in  the  cultivation  to  be  inoculated  and  drawn  rapidly  over  the  surface 
of  the  newly  prepared  potato. 

b.  Gelatinized  materials.    Solid  and  transparent  cultivating  media 


i  Where  these  glass  dishes  are  not  at  hand  a  very  excellent  substitute  is  a  soup  plate  with  a  meat 
plate  inverted  over  it,  each  having  been  washed  with  the  sublimate  solution  and  provided  with  the 
moist  blotting  paper. 


CHEYNE,  BACTERIOLOGY. 


85 


Fig.  16. 


can  be  made  by  adding  from  five  to  ten  per  cent,  of  gelatine  to  any  of 
the  fluid  media  previously  mentioned.  The  material,  however,  which 
seems  most  universally  useful  is  a  meat  jelly  of  the  following  composition  : 

Meat,  finely  chopped  1  pound. 

Water  .1  litre. 

To  the  meat  extract  thus  obtained  add : 

Peptone  10  to  30  grammes. 

Chloride  of  sodium   5  " 

Gelatine  100 

Neutralize  or  render  faintly  alkaline  with  carbonate  of  soda. 

The  meat  and  water  are  allowed  to  stand  in  an  ice  safe  for  twenty-four 
hours.  At  the  end  of  that  time  the  water  is  strained  off  and  the  fluid 
contained  in  the  meat  is  obtained  by  pressing  it  in  a  press,  this  fluid 
being  added  to  the  rest  and  the  whole  made  up  to  one  quart.  This  meat 
extract  is  now  boiled  to  precipitate  the  albumen,  then  the  peptone, 
common  salt,  and  gelatine  are  added  to  and  dissolved  in  it,  and  the  whole 
carefully  neutralized  by  means  of  carbonate  of  soda.  The  mixture  is  now 
filtered  through  a  warm  water  filter,  of  which  the  most  convenient  form 
is  shown  in  the  accompanying  diagram  (Fig.  16).  It  consists  of  a  glass 
funnel  fitted  into  a  copper  funnel  with  a 
space  between  them  in  which  water  lies. 

At  the  lower  part  the  glass  funnel  passes 
through  an  India-rubber  cork  which  is  fixed 
firmly  into  the  lower  opening  of  the  brass 
funnel,  thus  rendering  the  cavity  water- 
tight. In  one  form  a  hollow  brass  arm  is 
attached  to  one  side  of  the  brass  funnel 
and  the  water  in  the  funnel  alsc  passes  into 
this  arm.  By  means  of  a  lamp  placed 
under  this  arm  the  water  is  kept  warm.  In 
another  form  there  is  no  arm,  but  the  filter 
hangs  in  a  ring  which  is  a  hollow  tube 
through  which  the  gas  comes,  and  which 
has  a  number  of  small  burners  on  it.  Very 
often  the  material  must  be  filtered  more 
than  once  before  it  is  quite  clear.  In  hot 
weather,  if  the  filtration  occurs  slowly,  the 
jelly  is  apt  to  be  spoilt  by  decomposition 
before  it  is  ready.  To  facilitate  matters  I 
have  made  use  of  the  cook's  plan  of  clear- 
ing jellies  by  means  of  egg  albumen.  While 
the  material  is  cool  add  to  it  the  whites  and 

shells  of  two  or  three  eggs,  mix  well,  then  place  on  the  fire  and  boil 
violently  for  about  fifteen  minutes.    Care  must  be  taken  to  remove  the 


Hot  water  filter. 
A,  Bun  BOD    flame    playing  on  tho 
brass  arm  B. 


86 


CHEYNE,  BACTERIOLOGY. 


pot  and  scum  several  times  during  this  process,  otherwise  the  material  is 
apt  to  boil  over.  Then  strain  through  flannel.  The  result  is  that  with 
the  heat  the  egg  albumen  coagulates  and  rises  to  the  surface  as  a  scum, 
carrying  with  it  all  the  grosser  particles,  and  leaving  the  fluid  fairly 
clear.  AY  hen  this  has  been  strained  it  should  be  made  up  again  to  a 
quart,  filtered  and  tested  to  see  if  it  has  become  at  all  acid,  for  if  so  it 
must  be  again  neutralized.  It  will  now  be  found  to  run  through  much 
more  quickly.  In  filtering  it,  the  top  of  the  filter  should  be  covered 
with  a  plate  or  saucer  to  prevent  the  upper  part  of  the  filter  paper  from 
drying  up,  and  the  filtrate  should  be  received  into  a  purified  vessel. 

The  jelly,  when  filtered,  is  again  made  up  to  a  quart  and  may  be  placed 
in  a  pure  flask,  sterilized,  and  kept  as  a  stock  material,  but  it  is  usually 
put  at  once  into  the  smaller  vessels,  in  most  cases  into  test-tubes.  The 
test-tubes  are  washed,  plugged  with  cotton-wTool,  and  sterilized  in  the 
hot  box  as  previously  described.  It  is  very  convenient,  for  the  purpose 
of  handling  the  tubes,  to  place  them  in  crates  of  galvanized  iron-wire 
net  (Fig.  17)  each  holding  about  twrenty  or  thirty 
tubes.  They  are  sterilized  in  this.  When  filled 
they  are  again  arranged  in  the  crate,  and  can  be 
conveniently  placed  in  the  steaming  apparatus, 
taken  out  again,  etc. 

The  tubes  may  be  filled  in  various  ways; 
generally  about  one-fourth  of  their  interior  is 
occupied  by  the  jelly.  In  many  cases  it  is  im- 
portant to  know  how  much  jelly  is  present  in 
the  tube,  and  for  this  purpose  the  tubes  are  filled 
with  a  sterilized  graduated  pipette.  Generally 
about  10  c.cm.  are  put  into  each  tube.  The 
operation  is  performed  in  a  room  but  little  used, 
where  there  is  not  much  dust  flying  about.  The  tube  is  taken  between 
the  forefinger  and  the  thumb  and  held  obliquely  or  even  upside  down, 
while  the  cotton-wool  plug  is  extracted.  This  is  caught  by  the  outer 
part  between  the  little  and  ring  fingers,  the  tube  is  then  held  more  or 
less  upright,  the  pipette  with  the  jelly  rapidly  introduced,  care  being 
taken  to  avoid  wetting  the  neck  of  the  tube,  the  pipette  emptied  and 
withdrawn,  and  the  cotton-wool  plug  reinserted.  When  it  is  not  abso- 
lutely necessary  to  know  the  exact  quantity  it  is  much  more  convenient 
to  fill  them  from  a  Lister  flask  in  the  manner  before  described. 

The  jelly  must  now  be  sterilized,  and  this  is  done  by  means  of  the 
steaming  apparatus  as  before  described  with  fluids.  The  steamer  having 
been  raised  to  100°  C,  the  crates  or  flasks  are  introduced,  and  left  in  it 
for  ten  minutes  or  a  quarter  of  an  hour,  and  this  is  repeated  on  three 
successive  days.  Care  must  be  taken  not  to  heat  the  jelly  long  or  too 
often,  for  heat  converts  the  gelatine  into  acid  gelatine,  which  does  not 


Fig.  17. 


Crate  containing  test-tubes. 


CHE y NE ,  BACTERIOLOGY. 


87 


solidify.  Thus,  if  the  tubes  were  kept  at  the  temperature  of  100°  C. 
for  an  hour  or  more  for  three  successive  days,  the  jelly  would  probably 
not  set  at  all  or  only  do  so  very  imperfectly.  The  tubes  are  now  set 
aside  for  some  days  at  a  moderate  temperature  (16°  to  20°  C.)  to  see  if 
they  have  been  properly  sterilized.  If  the  jelly  remains  quite  clear  and 
free  from  the  development  of  colonies,  it  may  then  be  used  for  experi- 
mental purposes.  When  the  jelly  has  been  kept  in  the  tubes  for  some 
time  it  evaporates  at  the  upper  part,  and  then  when  a  wire  is  introduced 
to  inoculate  it,  it  splits.  Hence,  old  jelly  should  be  liquefied  and  allowed 
to  set  again  before  use. 

There  are  three  chief  modes  of  using  the  jelly  for  cultivations ;  these 
may  be  termed  test-tube  cultivations,  plate  cultivations,  and  glass  slide 
cultivations.  The  temperature  at  which  the  material  should  be  kept 
varies  from  16°  C.  to  23°  C.  or  25°  C.  Good  10  per  cent,  gelatine  is 
just  solid  at  25°  C,  while  very  few  organisms  grow  at  all  well  below 
16°  C.  The  best  temperature  for  growth  and  for  solidity  is  from  20°  C. 
to  22°  C. 

In  test-tube  cultivations  the  jelly  is  allowed  to  solidify  in  tubes  placed 
perpendicularly.  To  inoculate  these  tubes,  the  platinum  wire  fixed  in 
the  glass  handle  is  employed  (Fig.  18,  A).    The  wire  should  be  quite 

Pig.  18. 


A 


Platinum  needles  for  inoculation.    A,  straight  needle  for  inoculating  tubes.    B,  bent  needle  for 
glass  slide  cultivations.    C,  looped  needle  for  plate  cultivations.    (After  Crookshank.) 

straight  and  thin.  The  cotton-wool  plug  is  set  on  fire  to  destroy  all  the 
dust  on  its  outer  surface.  The  tube  is  then  held  obliquely  between  the 
fore  and  middle  finger,  the  plug  withdrawn,  and  caught  by  the  outer 
part  between  the  ring  and  little  finger,  the  wire  which,  as  well  as  the 
adjacent  piece  of  glass  rod,  has  been  heated  and  allowed  to  cool,  is  dipped 
in  the  material  to  be  inoculated  and  rapidly  plunged  into  the  jelly  right 
down  to  the  bottom  of  the  tube.  It  is  then  withdrawn,  the  plug  rein- 
serted, and  the  tube  placed  upright  at  a  suitable  temperature.  Where 
one  tube  is  to  be  inoculated  from  another,  the  new  tube  is  hold  between 
the  fore  and  middle  fingers  well  up  to  the  web,  and  the  old  tube  between 
the  middle  and  ring  fingers  near  their  tips,  and  the  cotton-wool  of  the 
new  tube  is  first  removed.    The  idea  is  that  if  all  the  dust  in  the  corks 


88 


CHEYNE,  BACTERIOLOGY. 


is  not  destroyed  by  the  burning,  it  will  not  much  matter  if  that  from  the 
cork  of  the  new  tube  falls  into  the  old  one ;  whereas,  if  the  opposite  were 
the  case,  the  new  cultivation  would  be  spoilt.  The  result  of  this  method 
of  inoculation  is  that  growth  may  occur  either  along  the  track  of  the 
needle  in  the  interior  of  the  jelly,  or  on  the  surface,  spreading  from  the 
point  where  the  needle  entered  the  jelly,  or  at  both  places,  and  from  this 
and  from  the  characters  of  the  resulting  growth,  valuable  information 
is  often  obtained  as  to  the  kind  of  bacterium  under  observation.  In 
some  cases  where  only  a  surface  growth  is  wanted,  it  is  most  convenient 
to  allow  the  jelly  to  solidify  obliquely,  and  then  inoculate  the  surface  by 
drawing  the  infected  needle  over  it.  In  keeping  up  a  series  of  cultiva- 
tions these  test-tube  cultivations  are  always  employed. 

Plate  cultivations  are  of  great  value  for  many  purposes — e.  g.,  for 
separating  bacteria  from  one  another  in  a  mixture ;  for  studying  the 
characteristics  of  particular  forms ;  for  ascertaining  the  number  present 
in  any  material,  or  whether  any  are  present  at  all,  etc.  In  this  method 
of  cultivation  a  tube  is  inoculated  with  the  material  to  be  investigated  ; 
the  jelly  is  liquefied  at  the  body  temperature;  it  is  then  well  shaken  to 


Fig.  19.  Fig.  20. 


Iron  box  in  which  the  glass  plates  used  for  plate  Arrangement  for  providing  a  level  surface 

cultivations  are  sterilized  and  kept.  for  plate  cultivations.   The  plan  described  in 

the  text  for  rapid  cooling  by  means  of  iced 
■water  is  not  shown  in  this  drawing. 

diffuse  the  bacteria  throughout  it,  and  before  it  sets  it  is  poured  out  on 
a  sterilized  glass  plate,  which  is  afterward  kept  at  a  proper  temperature 
in  a  moist  chamber,  protected  from  dust.  The  glass  plates  are  flat  pieces 
of  glass,  generally  oblong  in  shape,  and  measuring  about  six  inches  by 
four.  They  are  cleaned  and  placed  in  an  iron  box  like  that  shown  in 
Fig.  19.  This  box  containing  the  plates  is  sterilized  in  the  hot  box  in 
the  usual  manner.  The  dishes  used  for  keeping  the  plate  cultivations 
are  similar  to  those  employed  for  potatoes,  and  are  prepared  in  the  same 
manner.  Several  plates  may  be  placed  in  the  same  dish  by  using  a 
series  of  glass  supports  placed  one  above  the  other.  These  are  easily 
made  by  taking  a  long  narrow  piece  of  glass,  and  fastening  to  one  side 
of  it  at  each  end  a  thick  glass  bar  by  means  of  Canada  balsam.  In 


CHEYNE,  BACTERIOLOGY. 


89 


pouring  out  the  liquid  jelly  on  these  plates,  it  is  important  that  they 
should  be  level,  and  also  that  the  jelly  should  set  quickly.  For  this 
purpose  the  following  arrangement  is  employed :  A  large  wooden  tri- 
angle is  supported  by  three  screws,  which  can  be  raised  or  depressed. 
On  this  triangle  a  large  piece  of  glass  is  placed  (Fig.  20).  By  means 
of  a  spirit  level  and  the  screws  this  plate  can  be  made  quite  level.  On 
this  plate  a  glass  dish  is  set,  which  is  filled  quite  full  with  ice  and  water, 
and  over  this  another  flat  piece  of  glass  is  placed.  The  surface  of  this 
glass  is  levelled.  On  this  top  piece  of  glass  the  glass  plate  is  laid  and 
protected  from  dust  by  means  of  a  glass  cover.  The  liquid  jelly  is 
poured  out  on  this  plate  and  diffused  evenly  over  it  by  means  of  a  steri- 
lized glass  rod.  It  sets  almost  immediately,  and  can  then  be  placed  on 
a  glass  tray  in  the  prepared  dish,  and  another  plate  made,  and  so  on. 

The  result  is  that  the  bacteria  being  well  diffused  throughout  the  jelly, 
each  one  that  is  capable  of  growing  in  the  material  does  so,  and  thus 
a  number  of  masses  or  colonies  of  bacteria  appear  in  a  few  days  through- 
out the  jelly,  each  of  these  having  presumably  started  from  one  indi- 
vidual. Hence,  by  counting  the  number  of  colonies,  one  may  arrive 
at  the  number  of  individual  bacteria  introduced.  Again,  experience 
has  shown  that  different  species  of  bacteria  form  colonies  of  different 
appearances.  Some  are  round,  some  oval,  some  smooth,  some  tubercu- 
lated;  some  have  threads  shooting  out  from  them  into  the  jelly;  some 
are  colored,  some  not ;  some  cause  liquefaction  of  the  gelatine,  others  do 
not,  and  so  on.  By  observing  the  characteristics  of  the  colonies  one 
may  arrive,  by  means  of  plate  cultivations,  at  some  conclusion  as  to  the 
species  of  organism  under  observation.  Again,  by  means  of  this 
method,  one  can  not  only  enumerate  and  recognize  the  bacteria,  but 
can  also  get  pure  cultivations  from  a  mixture  of  different  kinds.  For 
if  the  bacteria  and  the  liquid  jelly  are  thoroughly  mixed,  and  if  the 
jelly  solidifies  rapidly,  each  colony  will  probably  start  from  a  single 
bacterium,  and  hence  each  colony  will  represent  a  pure  cultivation.  In 
separating  different  kinds,  one  would  not,  however,  be  content  with  a 
single  plate  cultivation ;  one  would  make  a  second  set  of  plates  from 
the  colonies  on  the  first.  If  all  the  colonies  in  the  second  series  of  plates 
are  similar,  one  may  assume  the  purity  of  each,  and  make  test-tube 
cultivations  from  them. 

The  examination  of  these  plates  may  be  carried  on  with  the  naked 
eye,  with  a  pocket  lens,  or  under  a  low  power  of  the  microscope.  In 
the  very  early  stage  the  colonies  are  so  small  that  they  can  only  be  seen 
under  the  microscope,  but  after  a  few  days  they  can  be  seen  and  recog- 
nized by  the  naked  eye  or  pocket  lens.  In  all  examinations  microscopic 
investigation  with  one-half  or  one-quarter  inch  objectives  should  be  com- 
bined with  the  examination  by  the  naked  eye  or  pocket  lens.  Being 
an  unstained  specimen  a  small  diaphragm  is,  of  course,  employed. 


90 


CHEYNE,  BACTEKIOLOGrY. 


For  any  of  the  purposes  for  which  plate  cultivations  are  employed,  it 
is  a  disadvantage  to  have  too  many  colonies  on  one  plate.  This  may  be 
avoided  in  various  ways.  Where  the  object  is  simply  to  get  plate  culti- 
vations for  diagnosis,  or  for  pure  cultivations,  I  generally  proceed  iu  this 
way.  Take,  say,  four  tubes  of  jelly  and  liquefy  them,  and,  in  burning 
off  the  tops  of  the  cotton-wool  corks,  heat  also  the  necks  of  the  tubes. 
Allow  them  to  cool,  and  introduce  a  minute  quantity  of  the  material  to 
be  tested  into  tube  No.  1.  Shake  it  well,  and  pour  one  or  two  drops 
from  No.  1  tube  into  No.  2.  Shake  No.  2  well,  and  pour  a  drop  or  two 
into  No.  3,  and  so  from  No.  3  into  No.  4.  Then  make  plates  from  each. 
In  No.  1  plate  the  colonies  will  certainly  be  too  numerous,  in  No.  2  this 
will  also  be  the  case,  but  in  No.  3,  and  especially  in  No.  4,  only  small 
numbers  will  be  present.  The  reason  for  heating  the  necks  of  the  tubes 
is  to  avoid  contamination  as  the  jelly  is  poured  from  the  one  tube  to  the 
other.  Koch's  plan  is  to  twist  the  end  of  the  platinum  wire  into  a  small 
loop  (see  Fig.  18,  C).  Dip  this  loop  into  the  bacteric  mixture,  and 
pass  it  into  the  jelly  in  tube  No.  1.  This  is  shaken  up,  and  from  this 
tube  three  loopfuls  are  carried  into  tube  No.  2  by  dipping  the  loop 
three  times  into  No.  1,  and  rinsing  it  out  each  time  in  No.  2.  From 
No.  2,  after  beiDg  shaken  up,  six  loopfuls  are  transferred  to  tube  No.  3. 
Plates  are  then  made  from  each.  Where  it  is  necessary  to  know  the 
number  of  bacteria  in  the  original  material,  one  must  proceed  differently. 
A  given  quantity,  say,  fifteen  minims,  of  the  original  material  is  added 
to  a  given  quantity  of  boiled  distilled  water,  or  salt  solution  (one-half 
per  cent.).  This  mixture  is  well  shaken  up,  and  then  a  small  quantity 
(say,  two  or  three  minims)  is  added  to  each  tube  of  jelly,  and  from 
these  plate  cultivations  are  then  made.  In  this  way,  by  a  simple  calcu- 
lation, the  number  of  bacteria  in  a  given  amount  of  the  original  mate- 
rial can  be  ascertained. 

Esmarch  has  introduced  a  plan  of  separating  bacteria,  which  is  useful 
in  the  absence  of  the  apparatus  for  plate  cultivations.  Instead  of  pour- 
ing out  the  contents  of  the  inoculated  tube,  the  latter  is  turned  on  its 
side  and  rotated,  under  a  stream  of  cold  water,  till  the  jelly  solidifies. 
The  whole  of  the  side  of  the  tube  is  thus  lined  with  a  thin  layer  of 
jelly  in  which  the  individual  colouies  appear ;  they  can  be  counted  and 
recognized  by  means  of  a  pocket  lens,  or  under  a  low  power  of  the 
microscope. 

Of  course,  in  these  processes  there  is  a  certain  risk  of  contamination. 
Contamination  from  the  neck  of  the  tube  is  avoided  by  the  precaution 
I  suggested  before,  of  heating  the  neck,  and  allowing  it  to  cool  before 
pouring  out  the  material.  Contamination  from  the  air  is  avoided  by 
rapidity  of  movement,  and  by  operating  in  a  still  room.  The  disturbing 
effects  of  an  accidental  contamination  are  also,  to  a  great  extent,  neu- 
tralized by  using  the  ice,  so  that  the  gelatine  solidifies  quickly,  for,  if 


CHEYNE,  BACTERIOLOGY. 


91 


anything  falls  from  the  air,  it  has  not  time  to  sink  into  the  jelly,  but 
remains  on  the  surface,  and  there  forms  its  colonies,  while  the  other 
organisms  are,  for  the  most  part,  in  the  interior  of  the  jelly. 

The  third  method  of  using  nutrient  jelly  is  for  glass  slide  cultivations. 
For  this  purpose,  either  the  glass  plates  before  mentioned,  or  the  ordinary 
microscopic  slides  are  employed.  They  are  sterilized  in  the  usual  manner, 
and  are  kept,  after  inoculation,  on  glass  trays  in  glass  vessels,  arranged 
as  for  plate  cultivations.  The  jelly  is  liquefied,  poured  out  on  the  glass 
slides,  and  allowed  to  solidify.  When  solid,  a  platinum  wire,  bent  at 
the  end  (see  Fig.  18,  B),  and  dipped  in  the  material  to  be  tested,  is  drawn 
lightly  and  rapidly  over  the  surface.  Generally,  a  number  of  slides  can 
be  thus  prepared  without  dipping  the  wire  a  second  time  in  the  mixture. 
The  result  of  this  procedure  is  that,  as  the  wire  passes  over  the  surface 
of  the  jelly,  it  shows  the  bacteria  along  its  track,  and  if  drawn  sufficiently 
lightly,  and  rapidly,  an  organism  will  only  be  deposited  here  and  there, 
especially  in  the  later  streaks.  There  are  two  advantages  of  this  method. 
In  the  first  place,  it  forms  one  plan  of  separating  bacteria,  for  many  of 
the  colonies  are  pure  cultivations,  and  are  sufficiently  distant  from  one 
another  to  enable  one  to  take  a  pure  cultivation  from  them.  And,  also, 
it  enables  one  to  test  the  purity  of  a  cultivation  more  readily  and  easily 
than  by  means  of  a  plate  culture,  for,  by  looking  along  the  needle  track 
under  the  microscope,  one  can  readily  see  whether  the  growth  is  all 
of  one  kind,  or  whether  more  than  one  form  is  present.  The  second 
advantage  is,  that  one  can  study  the  mode  of  spread  of  certain  organisms 
on  the  surface  of  the  jelly,  and  by  this  means  much  useful  information 
may  be  obtained.  From  these  cultures,  the  beautiful  impress  prepara- 
tions previously  mentioned  are  made. 

Nutrient  jelly  is  also  very  useful  for  cultivating  some  forms  of  anae- 
robes. For  this  purpose  very  long  tubes  are  used,  which  are  almost 
filled  with  jelly.  This  is  rendered  liquid,  and  then  the  material  con- 
taining the  supposed  anaerobes  is  introduced  and  thoroughly  shaken  up 
with  the  jelly.  If  nothing  but  anaerobes  are  present,  they  will  be  seen 
to  form  colonies  deep  down  in  the  tube,  while  a  certain  thickness  of  jelly 
at  the  upper  part  remains  pure.  If  both  aerobes  and  anaerobes  are 
present,  the  former  grow  at  the  top  and  the  latter  at  the  bottom.  By 
breaking  the  lower  part  of  the  tube  and  inoculating  fresh  tubes  in  the 
same  manner  from  the  colonies  at  that  part,  pure  cultivations  of  the 
anaerobic  organisms  will  ultimately  be  obtained. 

c.  Agar-agar.  Of  all  culture  materials  the  nutrient  jelly  is  the  most 
useful,  but  it  has  one  serious  defect,  viz.,  it  cannot  be  placed  at  the  tem- 
perature of  the  human  body  without  melting,  when,  of  course,  all  the 
advantages  of  the  solid  culture  are  lost.  Other  materials  which  will 
remain  solid  at  the  higher  temperature  have  been  tried.  Of  those  the 
chief  is  agar-agar,  a  material  derived  from  certain  plants  (gracilaria 


92 


CHEYNE,  BACTERIOLOGY. 


lichenoides).  Of  this  material  one  to  two  per  cent,  is  added  to  a  meat 
infusion  mixture,  prepared  in  the  same  manner  as  for  the  gelatine.  It 
is  allowed  to  swell  up  for  twenty-four  hours  in  the  ice-safe,  and  then  dis- 
solved in  the  steaming  apparatus.  It  is  extremely  difficult  material  to 
prepare,  and  is  never  quite  clear.  Hueppe  recommends  the  employment 
of  two  layers  of  filter  paper  in  the  funnel,  and  then  a  quantity  of  cotton- 
wool inside  them.  It  is  well  in  filtering  the  material  to  set  the  whole 
apparatus  in  the  steaming  apparatus,  and  keep  it  at  100°  C.  There  is 
no  danger  of  spoiling  the  solidity  of  the  material  by  heating  it  too  much. 
When  prepared,  it  is  introduced  into  and  preserved  in  test-tubes  in  the 
same  way  as  the  gelatine  material.  As  a  rule,  the  test-tubes  are  allowed 
to  solidify  obliquely.  Agar-agar  may  be  used  for  test-tube,  plate,  or 
glass  slide  cultivations.  In  using  it  for  plate  cultivations  great  care 
must  be  taken  not  to  kill  the  bacteria  introduced,  for  the  agar  does  not 
become  fluid  below  42°  C.  The  best  way  is  to  have  a  vessel  of  water  at 
42°  C.  at  hand.  Melt  the  agar  tube  in  the  steamer,  and  then  place  it 
in  this  water  until  the  temperature  of  the  whole  is  42°  C.  Then  add 
the  bacteria,  shake  up,  and  pour  out  rapidly  on  a  glass  plate. 

The  temperature  of  37°  C.  is  maintained  by  means  of  an  incubator, 
of  which  there  are  various  forms.  They  all  essentially  consist  of 
double-walled  copper  or  tin  vessels  with  either  a  lid  or  a  door  which 
is  also  double-walled.  The  space  between  the  walls  is  filled  with 
water.  A  thermometer  passes  through  a  hole  in  the  top  into  the  interior, 
and  a  gas  regulator  passes  into  the  water  to  regulate  the  supply  of  gas 
to  the  burner.  There  are  various  kinds  of  gas  regulators.  The  one 
most  frequently  employed  is  mercurial,  of  which  Keichert's 
Fig.  21.  is  the  best  form  (Fig  21).  It  consists  of  a  long  tube,  bul- 
bous at  the  bottom,  narrow  in  the  middle,  and  wide  at  the 
top.  To  the  narrow  part  at  the  side  is  attached  a  wider 
piece  of  glass  tube,  closed  with  metal,  in  which  a  screw 
works.  The  upper  wider  part  is  ground  inside,  and  has  a 
lateral  tube,  which  is  connected  by  India-rubber  tubing  with 
the  gas-burner.  Into  the  upper  part  is  inserted  a  T-shaped 
piece  of  glass  tubing,  ground  on  the  outer  side  of  the  upper 
part  of  the  leg  of  the  T,  and  tapering  toward  the  end 
inserted  into  the  long  tube.  This  tubing  is  open  at  two 
ends ;  at  the  outer,  or  larger  end,  it  is  connected  with  the 
K^ue]rat^rsas  gas  supply.  At  the  lower  end,  the  opening  is  comparatively 
small,  while  about  the  middle  of  the  descending  arm,  and 
opposite  the  large  exit  from  the  long  tube,  is  a  minute  hole.  The  bulb 
is  filled  with  mercury,  which  passes  up  the  narrow  tube  and  fills  the 
lateral  tube  on  the  narrow  part.  The  transverse  arm  of  the  T-shaped 
top  piece  is  connected  by  India-rubber  tubing  with  the  gas  supply.  The 
action  of  the  apparatus  is  as  follows  :  At  first,  gas  flows  freely  into  the 


CHEYNE,  BACTERIOLOGY. 


93 


T-shaped  piece,  and  thence  through  both  holes  into  the  upper  chamber 
of  the  long  tube,  from  which  it  passes  on  to  the  gas-burner  through  the 
lateral  tube.  As  the  water  becomes  warm,  the  mercury  rises  in  the 
narrow  tube  until  ultimately  it  gets  into  the  upper  dilated  part,  and 
closes  up  the  lower  and  larger  exit  for  the  gas.  Hence  gas  only  passes 
to  the  burner  through  the  minute  lateral  hole,  and  the  flame  diminishes. 
As  the  water  again  cools  the  mercury  falls,  until  at  length  the  lower 
hole  of  the  tube  is  freed,  and  a  full  flow  of  gas  again  takes  place.  By 
this  alternate  rising  and  falling  of  the  flame,  the  interior  of  the  chamber 
is  kept  at  a  constant  temperature.  The  regulation  for  a  definite  tem- 
perature (say  37°  C.)  is  done  in  this  way:  The  screw  of  the  lateral  tube 
is  unscrewed  as  far  as  it  will  go.    When  the  temperature  has  reached 


Fig.  22. 


Outline  of  d'Arsonval's  incubator.    A,  India-rubber  diaphragm.    B,  gas  tube.    C,  plug  and  tube 
at  the  top.    D,  lid.    E,  tray  on  which  cultures  are  placed.    F,  gas-burners. 

about  36°  C.  this  screw  is  screwed  in,  and  in  doing  so  displaces  the 
mercury  and  causes  it  to  rise  into  the  wide  top.  The  lateral  screw  is 
screwed  in  until  the  lower  exit  for  the  gas  is  shut  off,  and  the  flame  goes 
down.    Should  the  small  lateral  hole  still  allow  too  much  gas  to  escape, 


94 


CHEYXE,  BACTERIOLOGY. 


it  can  be  diminished  by  turning  round  the  top  piece  until  the  hole  is 
almost  closed  by  the  wall  of  the  long  tube.  The  most  perfect  incubator 
is  the  d'Arsonval  machine  made  by  Wiessnegg,  of  Paris,  and  outlined 
in  Fig.  22.  In  it,  the  regulation  occurs  by  the  expansion  of  the  water 
forcing  out  an  India-rubber  diaphragm  (A)  against  the  gas  tube  (B). 
In  this  case  boiled  water  must  be  introduced  into  the  machine,  in  order 
that  the  regulation  may  occur  solely  by  expansion  of  water  and  not  be 
complicated  by  expansion  of  gas. 

Agar  jelly  has  many  disadvantages  and  hence  is  not,  as  a  rule,  much 
used  except  to  maintain  pure  cultivations  of  microorganisms  which  only 
grow  at  the  temperature  of  the  body.  It  is  difficult  to  make,  never 
quite  clear,  difficult  to  utilize  for  plate  cultivations,  and  the  different 
bacteria  do  not  grow  with  characteristically  distinct  features  to  such  an 
extent  as  on  gelatinized  materials,  and  thus  its  diagnostic  properties  are 
less. 

d.  Blood  serum.  For  the  cultivation  of  tubercle  bacilli  and  other 
organisms  Koch  has  introduced  coagulated  blood  serum.    The  blood  of 

Fig.  23. 


Koch's  apparatus  for  sterilizing  blood  serum. 


sheep,  cattle,  etc.,  is  received  into  a  long,  narrow  clean  vessel  and  allowed 
to  stand  in  the  ice  safe  for  twenty-four  or  thirty-six  hours  till  the  serum 
has  separated.  The  clear  serum  is  then  drawn  off  and  introduced  into 
sterilized  test-tubes.  In  his  earlier  method  Koch  placed  these  tubes  in 
an  apparatus  (a  sort  of  incubator,  Fig.  23)  regulated  for  a  temperature 
of  58°  C.  to  60 0  C.    They  were  kept  in  this  for  an  hour  at  a  time,  and 


CHEYNE,  BACTERIOLOGY. 


95 


this  was  repeated  every  day  for  six  days  in  succession.  At  this  tempe- 
rature the  serum  does  not  solidify  while  all  the  adult  bacteria  are  killed, 
and  on  Tyndall's  principle  the  spores  sprout  in  the  interval  between  the 
heatings,  and  after  two  or  three  heatings  all  the  bacteria  are  destroyed. 
At  the  end  of  six  days  the  tubes  were  laid  on  the  bottom  of  another 
water  bath  which  could  be  placed  obliquely  (Fig.  24),  and  was  provided 


Tig.  24. 


Koch's  apparatus  for  solidifying  blood  serum.    Lateral  view.    (After  Hueppe.) 

with  a  glass  top  through  which  the  tubes  could  be  seen.  This  top  was 
covered  with  felt  when  not  used.  The  temperature  was  then  raised  to  from 
65°  C.  to  70°  C,  at  which  the  albumen  coagulated,  and  when  the  serum 
was  sufficiently  firm  the  tubes  were  removed  and  placed  in  an  incubator 
for  two  or  three  days  to  see  if  they  were  sterile.  If  the  temperature  is 
not  raised  above  70°  C,  the  serum  is  fairly  clear.  (Of  late,  Koch  has 
been  content  with  simply  solidifying  the  serum  slowly  at  65°  C.  at  once 
without  the  preliminary  exposures  to  58°  C.  A  certain  number  of  tubes 
remain  pure,  but  a  considerable  number  are  lost  in  this  method.)  When 
the  serum  has  solidified  and  is  allowed  to  cool,  a  little  condensed  steam 
runs  down  the  sides  of  the  tube  and  forms  a  drop  of  water  at  the  lower 
part  of  the  oblique  surface  of  the  blood  serum.  In  order  to  be  able  to 
look  at  the  growth  with  the  microscope,  the  serum  is  sometimes  solidified 
in  little  glass  capsules  provided  with  a  glass  cover  and  the  bacteria  are 
sown  on  this  by  stroking  it  with  the  platinum  wire. 

The  blood  serum  is  a  very  good  cultivating  medium  for  certain  bac- 
teria, more  especially  for  tubercle  bacilli,  but  it  is  troublesome  to  make 
and  by  no  means  the  best  medium  for  many  other  kinds.  Hence  its  use 
is  mainly  limited  to  tubercle  and  glanders  bacilli.  After  a  few  days  in 
the  incubator  the  upper  part  of  the  oblique  surface  of  the  blood  serum 
dries  up,  and  as  the  tubercle  bacilli  grow  very  slowly  it  is  important  to 
avoid  this.  This  may  be  done  by  fixing  a  small  India-rubber  cap  over 
the  mouth  of  the  tube,  but  this  is  dangerous  because,  if  spores  of  fungi 
have  fallen  on  the  cotton-wool,  they  grow  down  through  the  plug,  which 


96 


CHEYNE,  BACTERIOLOGY. 


is,  of  course,  quite  moist  under  the  cap,  and  fall  on  to  and  spoil  the 
cultivation.  To  prevent  this  the  top  of  the  cotton-wool  plug  must  be 
burned  and  washed  with  sublimate  solution  (i :  1000),  and  the  India- 
rubber  cap  must  also  be  washed  with  the  same  solution  before  it  is 
applied. 

Various  other  modifications  of  these  solid  media  have  been  used. 
Loffler,  in  cultivating  the  diphtheritic  bacillus,  added  to  three  parts  of 
the  blood  serum  one  part  of  a  neutralized  filtered  meat  infusion,  con- 
taining 1  per  cent,  peptone,  1  per  cent,  grape  sugar,  and  0.5  per  cent, 
chloride  of  sodium.  The  serum  was  then  sterilized  and  solidified  in  the 
manner  just  described. 

e.  Pastes.  For  fungi,  pastes  made  of  bread,  crushed  potato,  horse 
dung,  various  fruits,  etc.,  are  very  useful.  These  are  made  up  to  a  thick 
paste,  introduced  into  sterilized  Erlenmeyer's  flasks  and  sterilized  in  the 
usual  manner.    They  are  also  useful  for  various  bacteria. 

Pure  cultivations  of  the  various  microorganisms  may  either  be  ob- 
tained from  mixtures  of  various  kinds,  such  as  one  commonly  finds  in 
decomposing  materials,  etc.,  or  if  pathogenic  they  may  be  obtained  from 
the  affected  organism.  Most  forms  can  be  readily  obtained  from  mix- 
tures by  means  of  gelatine  or  agar  plate  cultivations,  or,  if  anaerobes,  by 
means  of  the  long  tubes  previously  described,  but  in  some  cases  where 
they  grow  slowly  they  either  cannot  be  got  at  all,  or  must  be  obtained 
from  some  place  where  they  already  exist  pure.  Take,  for  example,  the 
tubercle  bacillus  in  sputum.  The  tubercle  bacillus  grows  extremely 
slowdy  outside  the  body,  while  sputum  contains  large  numbers  of  other 
bacteria  which  grow  very  rapidly,  hence  any  attempt  to  obtain  the 
tubercle  bacillus  pure  by  means  of  glass  plate  cultivations,  or,  indeed,  in 
any  other  way  as  yet  known,  must  prove  a  failure.  They  can,  however, 
be  obtained  pure  by  introducing  them  into  a  soil  in  which  they  will 
grow  and  in  which  the  other  forms  will  not.  Such  a  soil  is  the  animal 
body,  but  it  is  quite  possible  that  a  similar  artificial  soil  might  be  pre- 
pared, though  this  has  not  yet  been  done  for  tubercle.  I  have,  however, 
in  the  case  of  certain  parasitic  skin  diseases,  more  especially  in  tinea  ton- 
surans, obtained  pure  cultivations  of  the  pathogenic  fungus  by  providing 
a  soil  wdiich  was  unsuitable  for  the  growth  of  the  bacilli  and  micrococci 
wdiich  swarm  on  the  hairs  and  yet  permitted  the  growth  of  the  fungus. 
Such  a  soil  was  obtained  by  adding  small  quantities  of  citric  acid  and 
extract  of  mix  vomica  to  the  ordinary  nutrient  jelly.  In  the  case  of 
other  slow-growing  and  spore-bearing  organisms,  it  might  be  possible  to 
get  them  pure  by  adding  an  antiseptic  to  the  mixture  so  as  to  kill  the 
other  bacteria,  and  then,  washing  the  antiseptic  away  and  sowing  the 
material,  the  spores  which  would  alone  survive  would  grow.  Or,  it 
might  be  done  by  heating  the  mixture,  as  spores  resist  heat.    In  such  a 


CHEYXE,  BACTERIOLOGY. 


97 


case  one  must  suppose  that  only  spores  of  the  particular  organisms  to  be 
cultivated  are  present  in  the  mixture. 

In  the  case  of  pathogenic  organisms  it  is  best  to  get  them  from  the 
body  of  the  animal  affected.  If  they  are  present  in  the  blood  this  is 
easily  done  by  killing  the  animal,  tying  it  out  on  its  back  on  a  board, 
and  washing  the  hair  and  skin  over  the  thorax  thoroughly  with  subli- 
mate solution  (1  :  500).  A  number  of  knives,  scissors,  and  forceps  are 
heated  in  the  gas-flame  and  allowed  to  cool.  With  one  the  skin  is 
divided ;  this  knife  is  then  heated  and  laid  aside.  With  another  the 
skin  is  dissected  off  the  thorax.  With  a  pair  of  scissors  the  ribs  (in 
rabbits  and  guinea-pigs)  are  cut  through,  and  with  a  fresh  knife  the 
sternum  is  dissected  up.  Again,  with  fresh  scissors  and  forceps,  the 
heart  is  seized  and  opened,  and  a  pure  platinum  needle  is  dipped  in  the 
blood.  The  glass  slide  cultivations  should  be  used  in  the  first  instance, 
for  by  this  means,  if  there  were  more  than  one  kind  of  organism  present 
in  the  blood,  or  if  any  accidental  contamination  occurred,  this  would  be 
at  once  detected  by  examining  the  line  of  growth,  and  pure  cultivations 
could  be  obtained  from  a  pure  spot.  If,  on  the  other  hand,  a  test-tube 
were  at  once  inoculated,  and  an  impurity  were  present,  an  impure  culti- 
vation would  be  obtained,  and  might  lead  to  error,  as  indeed  it  has  often 
done.  Where  the  bacteria  are  not  present  in  the  blood  but  in  the  organs, 
the  body  is  opened  in  the  same  manner ;  a  slice  is  made  into  the  organ, 
and  a  minute  piece  cut  out  with  pure  scissors,  and  sown  on  the  surface 
of  the  gelatine  or  agar.  It  sometimes  happens  that  the  animal  has  been 
dead  for  some  time  before  it  is  examined.  In  that  case  the  outside  of 
the  organ  may  be  covered  with  bacteria,  and  therefore  it  must  be  washed 
with  sublimate  solution,  and  a  cut  made  almost  across  it  with  a  pure 
knife.  As  the  knife  may  have  carried  in  bacteria  from  the  outside,  a 
fresh  cut  is  made  at  right  angles  to  this  with  a  fresh  knife,  and  to  make 
assurance  doubly  sure,  a  third  cut  is  made  at  right  angles  to  the  second, 
with  a  third  knife.  From  the  deeper  part  of  this  third  cut  small  pieces 
are  taken  and  used  for  -plate  cultivations,  glass  slide  cultivations,  etc. 
These  are  examples  of  the  methods  of  procedure ;  they  must  be  modified 
and  adapted  to  the- particular  cases  in  question. 

These  methods  of  cultivation  are  also  much  used  for  the  purpose  of 
ascertaining  the  number  and  kinds  of  bacteria  in  water,  earth,  and  air, 
and  the  results,  though  not  quite  exact,  nevertheless  give  a  great  deal  of 
useful  information.  The  results  are  not  as  yet  exact,  because  in  the  first 
instance  we  do  not  as  yet  know  all  the  pathogenic  organisms,  and  there- 
fore bacteria  may  grow  which  we  do  not  recognize  as  pathogenic.  In 
the  second  place,  all  the  pathogenic  organisms  may  not  grow  on  the  soil 
employed  or  in  the  presence  of  oxygen,  and  yet  these  special  forms  may 
be  present  in  large  numbers  in  the  material  tested.  And  in  the  third 
place,  they  may  grow  so  slowly  that  the  culture  material  may  be  com- 

NO.  CL2LXXV1I. — JTXY,  1887.  7 


93 


C  HEYNE ,  BACTERIOLOGY. 


pletely  invaded  by  other  forms  before  there  has  been  time  for  the  colonies 
of  the  pathogenic  organism  to  become  visible.  In  spite  of  these  dis- 
advantages, however,  much  information  may  be  obtained  as  to  the  sani- 
tary conditions  of  water  and  air  in  particular  localities,  for  the  presence 
of  a  large  number  of  bacteria  in  a  water  indicates  contamination  and 
the  existence  of  an  amount  of  pabulum  which  ought  not  to  be  there. 

The  examination  of  earth  is  easily  carried  out  by  pounding  up  some 
of  the  earth  to  a  fine  dust  in  a  sterilized  mortar  with  a  sterilized  pestle. 
A  minute  quantity  is  then  picked  up  on  the  point  of  a  sterilized  penknife 
and  scattered  over  the  surface  of  the  nutrient  jelly  which  has  been 
poured  out  on  a  glass  slide  and  allowed  to  solidify  (glass  slide  cultivation). 
Under  the  microscope  it  will  be  seen  that  growth  starts  from  the  majority 
of  the  particles  of  earth,  and  if  the  earth  has  been  pounded  up  sufficiently 
fine  most  of  these  centres  of  growth  will  be  pure  cultivations.  Hueppe 
recommends  that  as  anaerobes  are  always  present  in  earth,  some  of  the 
slides  should  be  covered  with  a  thin  strip  of  mica.  He  also  suggests 
that  a  quantitative  analysis  of  earth  may  be  made  by  mixing  a  certain 
weight  of  the  powdered  earth  with  a  certain  quantity  of  boiled  water, 
and  then  testing  this  in  the  same  manner  as  wTater.  This  method,  howT- 
ever,  can  only  yield  imperfect  results,  as  the  earth  quickly  subsides,  and 
it  is  not  easy  to  distribute  the  bacteria  equally  through  the  water,  many 
of  them  remaining  adherent  to  the  particles  of  earth.  Koch  has  shown 
that  the  majority  of  the  bacteria  in  earth  are  close  to  the  surface,  while 
deep  down  only  spores  and  anaerobic  forms  are  present. 

In  testing  water  one  has  to  take  into  account  both  the  numbers  and 
the  kinds  of  bacteria  present.  The  water  to  be  tested  must  be  received 
into  sterilized  vessels  and  corked  with  a  sterilized  cork  or  glass  stopper. 
A  definite  quantity  is  mixed  with  the  nutrient  jelly,  and  plate  cultiva- 
tions are  made.  As  a  rule,  in  the  case  of  filtered  water  eight  to  six- 
teen minims  may  be  added  to  three  drachms  of  jelly  without  much 
risk  of  having  too  many  colonies  as  a  result ;  but  with  unfiltered  wTater, 
or  very  impure  water,  much  smaller  quantities  must  be  used,  and 
indeed  in  some  cases  the  water  must  be  still  further  diluted  by  adding  a 
known  quantity  to  a  given  amount  of  boiled  distilled  water,  and  then 
using  a  certain  quantity  of  the  mixture  for  the  cultivation.  For  ease  in 
counting  the  colonies,  when  these  are  numerous,  the  glass  plate  is  laid 
on  a  piece  of  black  cardboard  divided  into  small  squares.  By  counting 
the  number  of  colonies  present  in  several  of  the  squares,  and  by  ascer- 
taining the  number  of  squares  occupied  by  the  jelly,  a  fairly  accurate 
estimate  of  the  numbers  can  be  arrived  at. 

Air  may  be  tested  in  various  ways.  By  the  older  plans  the  air  was 
aspirated  over  glycerine-covered  surfaces,  or  through  gun-cotton  which 
was  afterward  dissolved  in  alcohol  and  ether  and  in  other  ways,  and 
the  dust  so  collected  was  subjected  to  microscopical  investigation.  The 


CHEYNE,  BACTERIOLOGY. 


99 


results  of  this  plan  are  practically  nil,  for  it  is  impossible  to  recognize 
among  the  debris  what  are  and  what  are  not  living  organisms,  nor  what 
species  are  present.  Hence,  resort  is  now  always  had  to  cultivation  experi- 
ments. Miquel,  who  has  done  most  work  on  this  subject,  uses  for  the  most 
part  vessels  of  the  shape  shown  in  Fig.  25,  containing  cultivating  fluids. 

A  large  number  of  these  vessels  are  prepared 
and  the  pointed  extremity,  A,  being  broken 
off,  a  known  quantity  of  air  is  drawn  through 
each.  The  end  A  is  again  sealed  and  the 
bulbs  set  aside  in  a  warm  place  (e.  g.,  an 
incubator)   for   development.     A  certain 

Fig.  26. 


Fig.  25. 


Miquel's  bulb  for  testing  air  by  means 
of  cultivation.    (After  Hueppe.) 


Koch's  apparatus  for  testing  air.  A,  glass  cylinder. 
B,  strip  of  brass  or  tin.    C,  glass  capsule  for  jelly. 


number  of  bulbs  show  development,  a  certain  number  remain  pure.  By 
counting  the  number  in  which  development  occurs  and  ascertaining  the 
total  quantity  of  air  drawn  through  all  the  flasks  Miquel  estimates  the 
number  of  bacteria  in  that  amount  of  air.  This  method  is  totally 
untrustworthy  and  fallacious,  for  there  is  no  certainty  that  development 
in  each  flask  occurred  from  only  one  germ,  there  is  no  possibility  even 
on  microscopical  examination  of  determining  whether  each  is  a  pure 
cultivation  or  not,  and  one  cannot  tell  what  kinds  are  present. 

Hueppe's  method  is  a  great  improvement  on  this.  He  aspirates  a 
definite  quantity  of  air  through  a  certain  amount  of  culture  fluid  and 
then,  shaking  the  flask  well  to  distribute  the  bacteria  equally  through 
the  fluid,  he  makes  plate  cultivations  with  known  quantities  of  the  fluid 
in  nutrient  jelly  and  agar,  testing  the  mixture  of  air  and  culture  fluid 
in  the  same  way  that  water  is  tested. 

Koch  employed  a  glass  cylinder  six  centimetres  in  diameter  and  eighteen 
centimetres  high  (Fig.  26,  A),  at  the  bottom  of  which  is  placed  a  flat 
glass  capsule,  C,  to  hold  the  jelly ;  this  glass  capsule  can  be  easily  lifted 
out  of  the  cylinder  by  means  of  a  piece  of  tin  bent  at  right  angles,  B. 
The  cylinder,  capsule,  and  strip  of  tin  are  cleaned,  the  cylinder  plugged 
with  cotton-wool  and  the  whole  sterilized  in  the  hot  box.    When  the 


100 


CHEYNE,  BACTEKIOLOGrY. 


Fig.  27. 


vessel  has  cooled^the  cotton  plug  is  removed,  the  capsule  lifted  to  the 
margin  of  the  cylinder,  half  filled  with  nutrient  jelly  (for  this  purpose 
Koch  used  a  wheat  infusion  jelly),  replaced,  and  the  cylinder  immedi- 
ately replugged  with  the  wool.  Any  organisms  which  fall  in  during 
these  manipulations  sink  into  the  jelly  and  develop  in  its  interior  and 
not  on  the  surface.  When  the  jelly  has  set,  the  vessel  is  taken  to  the 
place  where  the  air  is  to  be  tested,  the  plug  removed  and  placed  in  a 
sterilized  vessel  and  the  cylinder  left  open  for  some  time  (even  for  some 
hours).  Dust  falls  on  to  the  jelly  and  after  a  sufficient  length  of  time 
the  plug  is  reinserted  and  the  apparatus  set  aside  for  development. 
Growth  occurs  at  various  points  on  the  surface  of  the  jelly.  This  method 
gives  a  rough  estimate  of  the  kinds  of  organisms  present  in  the  air,  but 
does  not  give  any  accurate  account  of  the  numbers 
present  in  a  given  quantity. 

Hesse  has  devised  an  elaborate  apparatus  for 
quantitative  analysis,  of  which  the  following  account 
may  be  given  from  his  paper : 

"  The  method  devised  by  me,  and  employed  in  my  in- 
vestigations, consists  essentially  in  drawing  air  through 
long  tubes,  the  walls  of  which  are  covered  with  a  layer 
of  solidified  nutrient  jelly.  The  current  of  air  is  regu- 
lated and  measured  by  means  of  an  aspirator.  From 
the  number  of  colonies  which  develop  on  the  jelly,  and 
from  the  quantity  of  air  employed,  an  accurate  estimate 
is  obtained  of  the  number  of  germs  in  the  air.  This, 
however,  gives  only  the  number  of  germs  which  come  in 
contact  with  the  nutrient  jelly,  and  which  can  grow  un- 
der the  conditions  under  which  they  are  placed,  such  as 
at  the  temperature  and  on  the  nutrient  soil  employed." 

Apparatus. — For  these  experiments  one  requires 
glass  tubing,  nutrient  jelly,  and  an  aspirator. 

"  Glass  tubing.  The  most  convenient  tubes  to  employ 
are  about  70  cm.  long  and  3.5  cm.  broad,  having  a  ca- 
pacity of  about  forty  cubic  inches.  The  tubes,  the  edges 
of  which  at  each  end  are  somewhat  thickened  or  bent 
outward,  are  now  prepared  for  the  reception  of  the  jelly ; 
over  one  end  a  closely  fitting  caoutchouc  cap  is  fastened, 
having  a  central  hole  of  about  one  centimetre  in  diam- 
eter, and  over  this  a  second  entire  cap  is  placed ;  in  this 
way  the  tube  is  completely  closed  at  this  end  (Fig.  27,  A). 
If  one  applies  only  a  single  cap  over  the  end  of  the 
tube,  as  I  did  in  my  early  experiments,  there  is  a 
danger  of  detaching  the  jelly  from  the  glass  when  the 
cap  is  removed,  and,  therefore,  I  used  to  cut  out  a  small 
central  hole  in  the  cap  before  the  commencement  of  the 
experiment;  but  by  the  use  of  two  caps  there  is  no  danger  of  disturbance 
of  the  jelly  by  the  removal  of  the  outer  cap. 

"  Into  these  tubes  50  c.  cm.  of  fluid  nutrient  jelly  are  introduced  by  means 
of  a  pipette.  This  quantity  is  sufficient  to  cover  the  inner  wall  of  the  tube 
completely. 

Into  the  other  end  of  the  tube  now  containing  the  jelly  a  tightly  fitting 


Tube  used  in  Hesse's 
method  of  testing  air. 
A,  end  covered  with  the 
caoutchouc  caps.  B, 
caoutchouc  cork.  C, 
glass  tube. 


caoutchouc  cork  (Fig.  27,  B)  about 


in  diameter  is  introduced.  The 


CHEYNE,  BACTERIOLOGY. 


101 


central  part  of  this  cork  is  perforated  with  a  hole  about  1  cm.  in  diameter, 
and  through  this  passes  a  piece  of  glass  tubing,  C,  about  10  cm.  long  and  1  cm. 
wide,  and  containing  two  plugs  of  cotton- wool.  The  plug  nearest  the  large 
tube  projects  a  little  beyond  the  end  of  the  small  glass  tube.  This  small  piece 
of  tubing  is  for  the  purpose  of  easily  connecting  the  large  tube  with  the  aspi- 
rator, of  equalizing  the  atmospheric  pressure  inside  and  outside  the  tube, 
and  of  acting  as  a  filter  for  the  air.  The  use  of  the  two  wool  plugs  is  in 
order  to  meet  requirements  to  be  referred  to  later,  which  make  it  desirable 
to  remove  a  part  of  the  contents  or  to  alter  the  position. 

"  The  tubes,  etc.,  are  by  no  means  free  from  micro-organisms  even  though 
the  greatest  care  and  cleanliness  be  observed.  Although  these  accidental 
impurities  could  be  recognized  from  the  position  in  which  the  colonies 
appear  (mostly  in  the  substance  of  the  gelatine),  nevertheless,  in  consequence 
of  their  further  development  the  result  of  the  experiment  would  not  be  satis- 
factory;  and  further,  the  innermost  wool  plug,  which,  as  will  be  later  seen, 
is  employed  to  control  the  accuracy  of  the  experiment,  would,  on  account  of 
its  contamination,  be  useless  for  that  purpose ;  hence,  it  is  necessary  to 
destroy  these  organisms.  This  is  most  conveniently  done  by  exposing  the 
tube  with  the  gelatine,  etc.,  for  one  or  two  hours  to  a  current  of  steam  at  or 
near  100°  C.  For  this  purpose  I  employ  an  apparatus  similar  to  that  described 
by  Koch,  GafFky,  and  Loffler  (Mittheihmgen  aus  d.  Gesundheitsamtes,  p.  332). 
By  means  of  it  six  tubes  can  be  sterilized  at  one  time.  It  consists  of  a  cylin- 
drical tin  vessel  about  1  metre  high  and  13  cm.  wide,  covered  with  a  tin  cap 
and  surrounded  by  felt;  this  cylinder  is  fixed  on  the  top  of  a  tin  vessel  20 
cm.  high  and  13.5  cm.  wide,  filled  with  water. 

"After  the  tube  has  been  removed  from  the  steaming  apparatus,  and  while 
the  jelly  is  still  fluid,  it  is  moved  in  various  directions  under  a  cold  water  tap 
till  the  jelly  solidifies.  Thus  an  even  coating  over  the  whole  tube  is  obtained, 
but  in  later  experiments  it  was  not  found  necessary  to  have  the  whole  wall  of 
the  tube  covered,  as  the  organisms  fell  on  the  side  on  which  the  tube  lay.  The 
tube  is  now  washed  externally  in  a  1  per  cent,  corrosive  sublimate  solution, 
and  fixed  horizontally  on  a  stand."  (This  stand  is  somewhat  similar  to  that 
used  in  photography.    See  Fig.  28.) 

By  means  of  an  elastic  tube  (A)  attached  to  the  narrow  glass  tubing 
the  aspirator  (B)  is  now  connected  with  this  tube.  (Hesse  generally  uses 
two  10  litre  flasks.)  The  one  nearest  the  apparatus  is  filled  with  water, 
the  other  is  empty.  By  setting  a  siphon  arrangement  into  action  the 
water  flows  from  the  upper  into  the  lower  flask,  and  the  air  which  takes 
its  place  must  pass  through  the  apparatus.  The  rapidity  of  flow  is  easily 
regulated  by  a  stopcock.  When  everything  is  ready,  the  outer  caout- 
chouc cap  over  the  end  of  the  large  tube  is  removed,  and  the  water  is 
made  to  flow  from  the  upper  to  the  lower  flask  at  a  moderate  rate.  It 
was  found  experimentally  that  all  the  dust  was  deposited  in]the  large 
tube,  unless  the  flow  was  very  rapid.  After  a  sufficient  quantity  of  air 
has  been  drawn  through,  the  aspirator  is  detached,  the  outer  cap  re- 
applied, and  the  tube  laid  horizontally  at  a  suitable  temperature  (20°  to 
25°  C).  In  two  or  three  days  colonies  are  evident,  and  may  then  be 
counted  and  investigated. 

None  of  these  methods  are  quite  satisfactory,  and  a  good  deal  remains 
to  be  done  in  the  way  of  improving  this  line  of  research.  Probably 
by  using  both  Hesse's  and  Hueppe's  plans  useful  results  would  be 
obtained. 


102 


CHEYNE,  BACTERIOLOGY. 


A  very  important  application  of  these  culture  methods  is  to  test  the 
value  of  antiseptics.  The  older  plans  for  testing  antiseptics  were  either 
to  add  a  certain  quantity  of  the  antiseptic  to  cultivating  fluids  and  then 
inoculate  with  some  putrid  material,  to  see  if  growth  occurred,  or  to  add 


Fig.  28. 


Hesse's  apparatus  for  testing  air  fixed  on  its  stand  and  ready  for  use. 
A,  elastic  tube  connecting  the  glass  tubing  with  the  aspirator.    B,  the  aspirator. 

the  antiseptic  substance  in  a  certain  quantity  to  the  mixture  of  bacteria, 
and  then  from  this  to  inoculate  a  cultivating  fluid.  There  are  several 
objections  to  this  plan.  For  example,  as  the  special  forms  of  bacteria 
tested  were  not  known  there  was  no  certainty  that  the  resulting  growth 
was  not  accidental.  Again,  no  account  was  taken  of  whether  the  bac- 
teria acted  on  were  in  the  spore  or  the  adult  condition. 

Koch  improved  this  method  very  much  by  using  only  known  and 
well-characterized  bacteria  in  his  experiments,  by  ascertaining  whether 
spores  were  present  or  not,  and  by  employing  solid  culture  media,  and 
thus  shutting  out  the  confusion  which  might  arise  on  account  of  acci- 
dental contamination.  He  also  increased  the  certainty  of  his  results  by 
employing  pathogenic  bacteria,  such  as  the  anthrax  bacillus,  and  after- 


CHEYNE,  BACTERIOLOGY. 


103 


ward  testing  the  result  by  inoculation  of  suitable  animals.  In  the  first 
place,  he  prepared  a  number  of  small  pieces  of  cotton  threads  by  put- 
ting them  into  a  tube  plugged  with  cotton-wool  and  sterilizing  them. 
He  then  made  a  copious  cultivation  of  the  organisms  or  spores  to  be 
tested,  soaked  a  number  of  the  threads  in  the  cultivation,  laid  them  in 
a  sterilized  watch-glass,  and  placed  them  in  a  drying  chamber  over  sul- 
phuric acid.  In  the  dry  state  non-spore-bearing  bacteria  may  live  three 
"or  four  days;  spores  live  a  long  time.  He  used  cultivations  of  a  large 
number  of  well-known  organisms,  such  as  Micrococcus  prodigiosus  for 
non-spore-bearing  bacteria,  and  anthrax  spores  for  spore-bearing  organ- 
isms. The  threads,  when  dry,  were  steeped  for  various  lengths  of  time 
in  solutions  of  the  antiseptic  of  different  strengths,  then  taken  out  and 
washed  in  boiled  distilled  water,  or  in  alcohol  and  ether,  and  laid  on 
potato,  or  on  jelly  poured  out  on  glass  slides.  In  a  few  days  it  was  evident 
whether  growth  had  occurred  or  not,  and  it  was  easy  to  determine  if  the 
growth  resulted  from  an  accidental  contamination,  or  from  the  organ- 
isms tested.  For,  if  the  latter,  the  growth  would  start  from  the  threads, 
and  would  also  show  the  characteristics  of  the  organism  in  question,  such 
as  the  color  of  Micrococcus  prodigiosus  on  potato,  or  the  peculiar  net- 
work growth  of  Bacillus  anthracis  on  jelly. 

In  testing  the  effect  of  acids  on  the  cholera  bacillus,1  I  adopted  a  dif- 
ferent plan,  which,  I  think,  has  advantages  over  the  other,  in  some 
cases.  A  cultivation  of  the  organism  in  question  in  fluids  is  prepared, 
and  a  certain  quantity  of  this  cultivation  is  added  to  a  certain  quantity 
of  a  solution  of  known  strength  of  the  antiseptic  to  be  tested,  well  mixed, 
and  allowed  to  stand  for  a  definite  time.  Tubes  containing  liquefied 
jelly  are  then  taken,  and  a  drop  of  the  mixture  of  bacteria  and  anti- 
septic is  added ;  they  are  then  shaken  up,  and  plate  cultivations  pre- 
pared. Control  experiments  are,  of  course,  made  to  make  sure  that  the 
amount  of  antiseptic  thus  added  to  the  jelly  is  not  sufficient  to  prevent 
growth.  The  jelly  is  already  liquefied  before  the  drop  of  the  mixture  is 
added  to  it,  in  order  that  the  antiseptic  may  be  at  once  diffused  through 
the  liquid,  and  not  continue  to  act  on  the  bacteria  for  a  longer  time  than 
was  intended. 

III.  The  Study  of  Bacteria  in  Relation  to  the  Living  Body. 

In  the  case  of  all  pathogenic  organisms  it  is  necessary  for  complete 
proof  that  they  are  the  cause  of  a  particular  disease  to  show  that,  on 
their  introduction  into  an  animal  of  a  species  susceptible  to  the  disease, 
they  set  up  the  disease  in  question.  Experiments  on  animals  arc  also 
required  in  the  case  of  bacteria,  in  order  to  study  the  mode  of  infection 
and  many  other  points  in  the  natural  history  of  the  disease.    Tin1  method 


1  See  Report  on  the  Cholera  Bacillus,  British  Medical  Journal,  May,  188"). 


104 


CHEYNE,  BACTEEIOLOGY. 


of  infection  varies  in  different  diseases,  but  the  following  are  the  chief 
modes  employed: 

A.  Cutaneous  Inoculation. — Here  a  wound  is  made  in  the  skin, 
but  does  not  pass  into  the  subcutaneous  tissue.  A  portion  of  the  body 
is  selected  which  the  animal  cannot  lick,  and  for  this  purpose  the  ear  is 
generally  chosen.  The  hair  is  shaved  off,  and  the  skin  washed  with 
sublimate  solution  (1 :  500),  which  is  again  removed  with  boiled  water. 
The  skin  is  then  scratched  with  a  sharp  lancet,  as  in  vaccination,  and 
the  infective  material  rubbed  into  the  scratch.  This  mode  of  infection 
acts  well  with  certain  organisms,  such  as  anthrax,  mouse  septicaemia, 
chicken  cholera,  etc. 

B.  Subcutaneous  Inoculation. — Other  organisms,  such  as  the  ba- 
cillus of  malignant  oedema,  the  tubercle  bacillus,  etc.,  must  be  introduced 
into  a  pocket  in  the  subcutaneous  tissue.  The  most  convenient  places 
for  this  pocket  are,  in  guinea-pigs  on  the  front  or  side  of  the  abdomen, 
in  rabbits  at  the  base  of  the  ear,  in  mice  at  the  root  of  the  tail.  The 
skin  is  shaved  and  disinfected  in  the  manner  before  described,  and  a 
small  incision  is  then  made  through  it  with  a  pair  of  sharp  scissors. 
With  some  blunt  instrument  a  pouch  is  then  formed  in  the  subcutaneous 
tissue,  and  into  this  the  material  to  be  tested  is  introduced  by  means  of 
a  platinum  wire,  point  of  a  knife,  etc.  After  it  is  introduced  the  skin 
is  rubbed  over  the  place  so  as  to  diffuse  the  material,  and,  if  necessary, 
the  wound  may  be  dressed  with  a  bit  of  salicylic  wool  and  collodion. 

C.  Subcutaneous  Injection. — The  back  or  the  front  of  the  abdo- 
men, and  the  root  of  the  ear  or  of  the  tail,  are  the  situations  most  fre- 


Fig.  29. 


Koch's  syringe  for  experiments  on  animals— old  pattern 


quently  selected.  The  skin  is  shaved  and  disinfected  as  before.  The 
material  is  drawn  up  into  a  syringe  of  special  construction,  and  the 
desired  quantity  is  injected.  The  older  form  of  syringe  introduced  by 
Koch  (Fig.  29)  consisted  of  a  glass  tube,  on  each  end  of  which  the 
thread  of  a  screw  is  cut,  and  the  metal  fittings  are  thus  screwed  directly 
on  to  the  glass.  The  piston  is  graduated,  and  the  bulbous  metal  end  is 
hollowed  in  the  middle,  and  does  not  fill  up  the  calibre  of  the  tube;  a 
sufficient  amount  of  cotton  or  asbestos  thread  is  wrapped  around  this 
end  of  the  piston  to  make  it  fit  the  tube  accurately.    The  washers  are 


CHEYNE,  BACTERIOLOGY. 


105 


made  of  thin  pieces  of  cork.  After  each  injection  the  cotton  thread  and 
the  washers  are  removed  and  the  syringe  is  washed.  Before  use,  fresh 
thread  and  washers  are  arranged,  and  the  whole  is  purified  in  the  hot 
box.  Of  late,  Koch  has  introduced  a  much  simpler  and  more  efficient 
form  of  syringe  (Fig.  30).    It  consists  of  a  straight  piece  of  glass  tubing 

Pig.  30. 


Koch's  syringe  for  experiments  on  animals — new  pattern. 


graduated  in  tenths  of  a  cubic  centimetre,  the  outer  side  of  each  end 
being  ground*  Over  each  end  metal  fittings  are  attached ;  one  taking 
the  needle  of  the  syringe,  and  the  other  having  affixed  to  it  an  India- 
rubber  ball  with  a  hole  at  the  top  and  a  stopcock  between  it  and  the 
syringe.  The  tube  and  the  lower  metal  attachment  can  be  sterilized  in 
the  hot  box  or  by  heating  them  directly  in  the  flame ;  the  upper  part 
does  not  require  to  be  sterilized,  as  it  does  not  come  in  contact  with  the 
injection  fluid.  By  pressing  the  ball  with  the  thumb  over  the  hole,  the 
contents  of  the  tube  are  expelled,  and  the  tube  is  filled  by  emptying  the 
ball  by  pressure,  and  then  allowing  it  to  fill  gradually  by  relaxing  the 
ball,  the  end  of  the  needle  being  dipped  in  the  fluid.  When  sufficient 
material  has  been  drawn  up,  the  stopcock  is  turned.  By  means  of  these 
syringes,  injections  may  be  made  not  only  into  the  subcutaneous  tissue, 
but  also  into  the  cavities  of  the  body  (abdomen  or  pleura). 

D.  Intravenous  Injections  may  be  Made  into  the  Jugular 
Vein  or  into  one  of  the  Aural  Veins. — If  the  injection  is  to  be 
made  into  the  jugular  vein,  the  animal  must  be  chloroformed  and  tied 
out  on  its  back.  The  skin  being  shaved  and  disinfected,  and  the  knives, 
forceps,  etc.,  also  disinfected,  an  incision  is  made  over  the  jugular  vein 
on  one  side,  a  double  ligature  passed  round  it,  and  between  the  two 
ligatures  a  small  V-shaped  incision  is  made  into  the  vein,  into  which  the 
nozzle  of  the  canula  is  introduced  and  tied ;  the  vein  is  also  tied  above. 
Injection  may  be  made  by  a  syringe  through  the  canula,  but  I  have 
always  found  it  best  when  large  quantities  were  introduced  to  use  a 
burette,  and  let  the  fluid  pass  in  slowly  and  without  any  force. 


106 


CHEYNE,  B ACTEKIOLOGY. 


It  is  much  simpler  to  inject  into  the  aural  vein.  A  vein  is  selected 
at  the  outer  side  of  the  edge  of  the  ear,  where  the  skin  does  not  move 
over  the  vein,  nor  the  vein  over  the  cartilage.  The  skin  is  shaved  and 
then  disinfected,  and  then  the  needle  of  one  of  Koch's  syringes  is  pushed 
directly  into  the  vein  and  the  material  injected.  It  is  easy  to  see  if  the 
needle  is  in  the  vein,  and  whether  the  injection  flows  properly  or  not. 

E.  The  eye  may  be  very  conveniently  used  for  inoculation,  as  it  allows 
one  to  observe  what  takes  place  afterward.  In  some  cases  the  cornea 
only  is  inoculated  by  pricking  it  with  an  infected  needle  and  the  spread 
of  the  organisms  along  the  spaces  in  the  cornea  can  be  observed. 

The  most  frequent  mode  of  using  the  eye  is,  however,  to  introduce  the 
infective  material  into  the  anterior  chamber  of  the  eye.  This  is  more 
especially  useful  in  the  case  of  bacteria  which  grow  slowly  and  do  not  set 
up  much  inflammation,  such  as  the  tubercle  bacillus.  In  fact,  in  regard 
to  tubercle,  this  method  has  been  most  valuable  in  clearing  up  many 
points,  more  especially  in  disproving  the  assertions  as  to  the  origin  of 
tuberculosis  as  a  result  of  the  introduction  of  non-tuberculous  material 
into  rodents.  When  non-tuberculous  material  such  as  pieces  of  glass, 
cork,  etc.,  were  introduced  into  the  abdominal  cavity  and  the  animal 
died  afterward  of  tuberculosis,  it  might  have  been  that  the  material  set 
up  the  tuberculous  process,  or  on  the  other  hand  that  the  occurrence  of 
tuberculosis  was  independent  of  the  operation.  When  tuberculous 
material  is  introduced  into  the  anterior  chamber  of  the  eye  of  a  rabbit, 
it  remains  there  for  some  days  without  apparently  causing  any  disturb- 
ance— in  fact,  gradually  dwindling  away,  till  in  about  twenty-one  days 
an  eruption  of  tubercle  is  noticed  on  the  iris,  and  thence  the  disease 
spreads,  affecting  the  whole  eye  and  in  most  instances  spreading  to  the 
body  and  setting  up  general  tuberculosis.  This  iris  tuberculosis  always 
occurs.  If  a  piece  of  cork  or  other  non-tuberculous  material  is  intro- 
duced into  the  anterior  chamber  of  the  eye,  it  is  not  followed  by  an  iris 
tuberculosis,  and  should  the  animal  afterward  die  of  general  tuberculosis 
(which  occurs  extremely  rarely),  it  is  thus  known  that  the  disease  was 
accidental  and  independent  of  the  operation.  In  introducing  the  material 
the  eye  is  fixed  and  a  small  incision  is  made  at  the  upper  part  of  the 
cornea  into  the  anterior  chamber,  care  being  taken  as  the  knife  is  with- 
drawn that  the  iris  does  not  prolapse.  The  material  is  then  pushed  into 
the  anterior  chamber  through  this  opening  by  means  of  a  blunt  needle. 
Fluids  may  also  be  injected  into  the  anterior  chamber  by  Koch's  syringe, 
the  needle  being  pushed  obliquely  through  the  upper  part  of  the  cornea. 

F.  Inhalation, — In  some  cases  it  is  necessary  to  test  the  effect  of  in- 
halation of  virulent  material  in  producing  disease.  In  doing  so  the  ex- 
perimenter must,  as  a  rule,  guard  against  the  danger  to  himself.  The 
infective  material  may  be  furnished  for  inhalation  either  in  the  form  of 
spray  or  as  dust.    In  the  case  of  spray  the  animals  are  placed  in  a  box 


GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA. 


107 


into  which  the  nozzle  of  a  hand  spray-producer  projects.  The  retort  of 
the  spray  contains  the  infective  mixture,  and  the  operator  is  separated 
from  the  spray  by  a  long  India-rubber  tube.  If  necessary,  he  may 
shield  himself  by  means  of  a  respirator;  but,  as  a  rule,  the  box  can  be 
placed  in  the  open  air  and  at  such  a  distance  away  that  he  is  in  no  danger. 

Spore-bearing  organisms  may  be  used  in  the  form  of  dust,  which  may 
be  either  blown  into  the  vessel  containing  the  animal  or  placed  on  the 
floor  of  the  vessel,  which  is  then  shaken  to  raise  the  dust. 

G.  Infection  by  the  Food. — This  mode  of  experimentation  is  used 
to  test  the  possibility  of  infection  from  the  intestine,  and  in  carrying  it 
out  there  are  two  points  to  be  attended  to:  care  must  be  taken,  first, 
that  infection  does  not  occur  from  the  mouth  or  throat ;  and,  secondly, 
that  the  infective  material  is  not  destroyed  in  the  stomach.  At  first  the 
experiments  were  made  by  simply  mixing  the  infective  material  with 
the  food,  but  in  these  cases  infection  often  occurred  from  the  mouth  and 
throat.  To  avoid  this,  Koch  adopted  the  plan  of  taking  two  small 
slices  of  boiled  potato,  scooping  out  a  small  depression  in  each  piece, 
filling  this  depression  with  the  bacteria,  placing  the  two  slices  in  apposi- 
tion so  that  the  bacteria  were  enclosed  in  the  potato,  and  pushing  the 
piece  of  potato  to  the  back  of  the  tongue  so  that  it  was  swallowed  at 
once  without  being  chewed. 

As  regards  the  second  danger,  it  is  only  present  in  the  case  of  non- 
spore-bearing  bacteria.  Spores  are  able  to  resist  the  action  of  the  gastric 
juice,  whereas  adult  forms  are,  as  a  rule,  destroyed  by  it.  In  the  case  of 
the  cholera  bacillus,  Koch  has  devised  a  plan  in  the  case  of  guinea-pigs 
by  which  the  bacilli  escape  the  action  of  the  gastric  juice.  He  first  neu- 
tralizes the  contents  of  the  stomach  by  introducing  into  it  eighty 
minims  of  a  five  per  cent,  solution  of  carbonate  of  soda.  Ten  minutes 
later  a  culture  of  the  cholera  bacillus  is  injected  through  a  stomach  tube 
(catheter).  Lest  the  bacteria,  which  thus  escape  the  action  of  the  gastric 
juice  and  enter  the  intestine  alive,  should  pass  too  rapidly  through  the 
small  intestine,  he  then  injects  a  solution  of  opium  into  the  abdominal 
cavity  (sixteen  minims  of  the  tincture  for  every  six  ounces  of  the 
weight  of  the  animal).  Koch  hopes  that  this  plan  will  prove  useful  in 
testing  other  forms  of  bacteria. 


THE  ETIOLOGY  AND  MECHANISM  OF  ASTHMA. 
By  William  C.  Glasgow,  M.D., 

PROFESSOR  OF  DISEASES  OF  THE  CHEST  AND  THROAT  IN  THE  ST.  LOUIS  POST-GRA DUATE  SCHOOL  OF  MF.Dlflvr  ; 
ADJUNCT  PROFESSOR  OF  THEORY  AND  PRACTICE  IN  THE  ST.  LOUIS  MEDICAL  COLLEGE. 

No  subject  in  medicine  has  given  rise  to  greater  discussion  or  criticism 
than  that  included  in  the  term  "Asthma."  It  was  indiscriminately 
applied  by  the  older  writers  to  dyspnoea  arising  from  various  causes,  and 


108     GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA. 


at  the  present  time,  although  the  majority  confine  the  term  to  paroxysmal 
dyspnoea,  accompanied  by  characteristic  physical  signs,  still  we  find  it 
used  in  a  loose  way  to  describe  dyspnoea  due  to  entirely  different  patho- 
logical conditions. 

In  this  article  I  wish  to  confine  the  term  to  the  paroxysmal  dyspnoea 
which  is  always  characterized  by  positive  physical  signs.  I  will  exclude 
from  consideration  all  other  forms.  Cardiac  asthma  due  to  a  weakening; 
of  the  heart,  is  not  asthma ;  nor  can  we  include  the  smothering  of  pure 
emphysema,  although  emphysema  may  be  complicated  with  asthma. 
Suffocative  attacks  of  bronchitis  belong  to  the  latter  disease,  although 
asthma  may  be  also  engrafted  upon  it  and  immeasurably  increase  the 
distress  of  the  sufferer.  In  various  diseases  of  the  nervous  system  there 
is  marked  and  paroxysmal  dyspnoea,  but  the  physical  signs  of  asthma 
are  always  absent. 

The  older  writers  divided  asthma  into  idiopathic  or  essential,  and 
reflex.  In  the  class  of  idiopathic  asthmas  were  included  all  for  which 
no  reflex  origin  could  be  discovered  ;  whilst  in  those  classed  as  reflex, 
the  point  of  irritation  was  mainly  found  in  the  bronchi  and  the  mucous 
membrane  of  the  gastro-enteric  canal,  the  uterus,  or  the  uterine  appen- 
dages. The  number  of  reflex  cases  was  limited,  and  the  large  majority 
of  cases  were  classified  as  idiopathic. 

Modern  investigations  have  proven  that  asthma  of  reflex  origin  is  the 
most  common,  and  at  the  present  day  it  seems  not  improbable  that  those 
cases  for  which  no  local  point  of  irritation  can  be  disco  verecl,  aud  which 
seem  idiopathic  in  character,  will,  by  later  investigators,  be  brought  into 
the  reflex  class.  Emotional  asthma  seems  to  be  most  certainly  of  the 
essential  character;  but  when  we  consider  it  as  analogous  to  vasomotor 
disturbances  of  the  skin  seen  in  emotional  states,  causing  blushing  or 
pallor,  we  may  find  a  reflex  origin  through  some  of  the  senses. 

Voltalini  first  drew  attention  to  asthma  dependent  on  the  presence  of 
nasal  polypi,  and  showed  that  the  removal  of  the  polypi  was  followed  by 
a  cessation  of  the  asthma.  Later  investigations  have  proven  that  it  is 
not  the  polypi  alone,  but  rather  the  peculiar  condition  of  the  nasal 
chamber  in  which  the  polypi  are  found  that  is  the  immediate  cause  of 
the  asthmatic  attack.  Hack  and  John  Mackenzie,  of  Baltimore,  have 
especially  drawn  attention  to  the  fact  that  a  condition  of  congestion 
is  at  times  present,  and  that  the  cavernous  tissues  of  the  turbinated 
bones  become  hypersesthetic.  They  have  endeavored  to  prove  that  the 
special  sensitive  areas  are  found  either  at  the  anterior  or  posterior 
extremities  of  the  turbinated  bones.  It  has  now,  however,  been  proven 
that  the  whole  surface  of  the  membrane  is  involved  more  or  less  in  this 
sensitive  area.  In  this  sensitive  condition,  the  presence  of  an  irritant  is 
capable  of  producing  the  asthmatic  paroxysm.  A  polypus  touching  the 
sensitive  area,  retained  secretions,  dust,  intense  light,  or  anything  capable 


GLASGOW,  ETIOLOGY  A  XD  MECHANISM   OF  ASTHMA.  109 


of  producing  an  impression  on  the  nasal  mucous  membrane  will  provoke 
the  attack.  Even  a  swollen  condition  of  the  mucous  membrane  allow- 
ing a  lateral  pressure  between  the  septum  and  the  cavernous  bodies, 
seems  to  be  a  provoking  cause.  That  a  nasal  polypus  alone  is  not 
capable  of  producing  asthma,  is  shown  by  a  case  in  which  I  removed  a 
polypus  from  the  lower  turbinated  bone  with  complete  cessation  of  the 
asthmatic  symptoms,  although  the  upper  portion  of  the  chamber  was 
still  filled  with  nasal  polypi.  The  asthma  subsequently  returned  on  a 
recurrence  of  the  lower  polypus. 

In  the  pharynx  we  find  an  immediate  cause  in  the  presence  of  hyper- 
sesthetic,  enlarged  follicles.  In  a  case  of  this  character  the  asthma  was 
modified  by  an  application  to  the  group  of  follicles,  and  disappeared 
after  the  destruction  of  the  same. 

In  1882  I  presented  to  the  American  Laryngological  Society  a  paper 
termed  "  Laryngeal  Asthma."  In  this  article  I  sought  to  prove  the  con- 
nection between  a  hypersemic  or  inflamed  condition  of  the  larynx  and 
the  asthmatic  paroxysm.  I  cited  several  cases  where  the  asthmatic 
paroxysm  had  been  modified  or  entirely  removed  by  the  application  of 
an  anaesthetic  or  astringent  solution  to  the  larynx.  The  sensitive  area 
is  especially  the  inter-arytenoidal  space  and  the  membrane  over  the 
arytenoid  cartilages.  Since  then  I  have  seen  a  large  number  of  these 
cases,  and  will  cite  the  following  as  illustrative : 

Through  a  misplacement  of  bottles,  I  pencilled  the  larynx  of  a  man 
suffering  wTith  a  severe  asthmatic  paroxysm,  with  a  fifty  per  cent,  solu- 
tion of  carbolic  acid.  The  application  caused  intense  burning,  and  the 
patient  was  able  to  swallow  with  great  difficulty  for  several  days.  The 
asthmatic  paroxysm,  however,  -was  instantly  broken  on  the  application  of 
the  brush,  and  since  then  he  has  been  entirely  free  from  asthma.  .  I  could 
report  many  cases  in  which  the  spasm  has  been  instantly  modified  or 
entirely  broken  by  the  application  to  the  larynx  of  a  mild  solution  of 
carbolized  iodine,  or  the  insufflation  of  morphia  powder.  From  the 
success  of  this  form  of  treatment,  the  immediate  and  at  times  almost 
instantaneous  relief  given,  I  feel  justified  in  saying  that  the  sensitive 
area  of  the  larynx,  in  a  large  number  of  cases,  is  the  site  of  localized 
irritation  provoking  the  asthmatic  attack.  From  a  study  of  a  large 
number  of  asthmatics,  I  am  fully  convinced  that  the  local  site  of  irrita- 
tion in  the  greater  number  lies  in  the  upper  air-passages.  Storck,  Noth- 
nagel,  Long-et,  and  Schiff,  have  demonstrated  that  the  sensitive  cough  area 
is  located  in  the  inter-arytenoidal  space,  the  posterior  surface  of  the 
trachea,  and  at  the  bifurcation  of  the  bronchi.  Later  investigators 
(Hack,  Haring,  John  Mackenzie,  Daly,  and  Roe  have  added  to  these 
the  surface  of  the  lower  and  middle  turbinated  bones. 

Many  cases  of  so-called  bronchial  asthma  have  their  Bite  of  irritation 
in  the  nares,  in  the  larynx,  and  probably  in  the  posterior  surface  of  the 


110     GLASGOW,  ETIOLOGY  AND   MECHANISM  OF  ASTHMA. 

trachea,  and  the  bifurcation  of  the  bronchi.  Cases  of  asthma  caused 
by  odors,  the  effluvia  of  animals,  and  the  smell  of  flowers,  or  light,  are 
due  probably  to  a  pathological  condition  of  the  nares.  I  am  also 
inclined  to  believe  that  asthma  due  to  emotional  or  psychical  influence 
may  in  certain  cases  be  due  to  the  same  cause.  It  is  fully  recognized 
that  the  so-called  vasomotor  catarrh,  with  turgescence  and  hyperemia 
of  the  cavernous  bodies,  may  be  produced  by  mental  impressions,  the 
rose  experiments  of  Dr.  John  Mackenzie  being  a  striking  example.  It 
is  also  a  well-known  fact  to  laryngologists  that  a  transient  flushing  or 
blushing  of  the  mucous  membrane  takes  place  when  the  light  of  the 
reflector  is  thrown  upon  it.  The  following  case  is  interesting  as  showing 
the  dependence  of  a  changed  condition  of  the  cavernous  bodies  on  a 
psychical  influence.  In  a  patient  of  the  St.  Louis  Post-Graduate  Poly- 
clinic the  cavernous  tissue  of  the  nose  was  greatly  swollen.  I  proposed 
to  excise  a  portion  of  it.  She  demurred  strongly,  and  when  I  insisted, 
became  very  much  frightened  :  on  looking  again,  I  was  astonished  to 
find  that  the  swollen  tissue  had  become  much  paler,  and  had  been 
reduced  in  size  fully  one-half.  This  was  fully  observed  by  members  of 
the  class. 

Uterine  asthma  and  peptic  asthma,  on  which  so  much  stress  has  been 
laid  by  Hyde  Salter,  may  also  have  a  possible  connection  with  a  certain 
condition  of  the  upper  air-passages.  The  coincidence  of  paroxysms  of 
nervous  dyspnoea  wTith  certain  conditions  of  the  uterus  and  its  appen- 
dages, is  well  authenticated ;  but  wThether  these  paroxysms  are  real 
attacks  of  asthma  or  spells  of  nervous  dyspnoea,  in  which  we  find  rapid 
breathing  with  great  iutensity  of  the  respiratory  sounds,  but  no  asthmatic 
rales,  has  not  been  so  conclusively  established. 
•  Hyda  Salter  relates  one  case,  reported  by  another  physician,  in  which 

real  asthmatic  attacks  occurred  during  pregnancy  ;  and  Engelmann,  of  St. 
Louis,  has  noted  a  case  in  which  asthmatic  attacks  followed  a  retroflexed 
position  of  the  uterus,  and  disappeared  with  the  reposition  of  the  organ ; 
but  in  this  case  there  is  no  record  of  the  presence  of  asthmatic  rales. 
Paroxysmal  nervous  dyspnoea  is  quite  a  frequent  accompaniment  of  a 
disturbed  condition  of  the  nervous  system.  It  is  seen  in  hysteria,  neur- 
asthenia, and  spinal  irritation ;  it  is  seen  in  connection  with  disorders 
of  the  uterus  or  its  appendages,  and  also  in  cases  of  impoverishment  of 
the  blood  or  blood-poisoning.  Resembling  true  asthma  in  its  paroxysmal 
attacks,  it  is,  however,  a  distinctly  different  disorder.  The  dyspnoea  is 
rather  a  rapid  panting  than  the  labored  breathing  of  asthma  ;  the  respi- 
ratory sounds  are  simply  intensified  normal  sounds,  and  the  asthmatic 
rales  are  absent. 

That  asthma  occurs  at  many  of  the  critical  periods  of  female  life  is 
certainly  true.  In  regard  to  pregnancy,  I  have  seen  two  cases  in  which 
the  asthma  disappeared  with  conception,  and  has  not  since  returned. 


GLASGOW,  ETIOLOGY  AND   MECHANISM   OF  ASTHMA. 


Ill 


Both  of  these  patients  were  asthmatics  of  long-  standing.  It  is  in  these 
cases  of  uterine  asthma  that  we  can  find  often  a  possible  nasal  origin  for 
the  attacks.  The  connection  between  the  condition  of  the  cavernous 
bodies  and  uterine  changes  is  very  marked.  Many  women  at  the  men- 
strual epoch  have  vasomotor  catarrh,  with  great  turgescence  of  the 
cavernous  bodies  and  the  mucous  membrane.  This  condition  in  itself 
has  been  shown  to  be  a  sufficient  cause  for  the  attack,  irrespective  of  the 
pathological  condition  of  the  uterus.  The  peptic  asthma,  on  which  so 
much  stress  is  laid  by  Hyde  Salter,  may  be  fully  explained  by  referring 
the  irritation  to  the  larynx.  Gastric  pharyngitis  and  gastric  laryngitis 
are  recognized  forms  of  throat  disease.  They  are  dependent  upon 
functional  gastric  disturbance,  with  the  production  of  fermentation  and 
acid  secretions.  In  the  peptic  asthma  quoted  by  Hyde  Salter,  the 
paroxysms  occurred  during  the  end  of  the  digestive  process,  showing 
that  the  mere  presence  of  food  is  not  sufficient  to  cause  the  attack.  The 
majority  of  asthmatics  are  dyspeptics,  and  it  is  possible  that  these  cases 
were  subject  to  a  gastric  laryngitis,  in  which  the  sensitive  area  of  the 
larynx  was  involved.  A  similar  condition  is  found  to  exist  in  so-called 
stomach  cough.  Although  the  local  seat  of  irritation  seems  to  be,  in  the 
majority  of  cases,  in  the  upper  air-passages,  it  is  probable  that  a  disor- 
dered condition  of  other  organs  exerts  a  positive  influence  in  provoking 
the  attack.  As  this  is  true  in  other  nerve  disorders,  as  migraine,  epilepsy, 
and  neuralgia,  it  is  equally  probable  in  asthma.  For  example,  in  a 
person  with  a  disposition  to  asthma,  the  attacks  may  only  attain  the 
degree  of  the  first  stage,  and  give  rise  to  scarcely  noticeable  symptoms. 
When,  however,  an  increased  irritation  is  added,  as  would  occur  through 
a  disorder  of  the  gastro-enteric  canal  or  uterine  disease,  this  added 
element  would  be  sufficient  to  increase  the  irritation,  and  the  first  stage 
would  grow  into  the  second  with  the  appearance  of  all  the  well-known 
asthmatic  symptoms.  A  similar  condition  is  found  in  neurotic  palpita- 
tions occurring  in  a  heart  weakened  by  anaemia,  where  a  torpid  liver 
would  provoke  a  disturbance,  which,  in  a  normal  condition  of  the  secre- 
tions, would  be  absent. 

All  writers  on  asthma  have  noticed  the  great  difference  in  the  severitv 
of  the  paroxysms  not  only  in  different  individuals,  but  even  in  the  same 
individual  at  different  times.  Walsh  has  even  assumed  two  forma  of 
the  disorder,  one  seemingly  dependent  on  a  spasmodic  and  the  other  on 
a  paralytic  condition  of  the  bronchial  muscles.  If  the  asthmatic  be 
closely  studied  during  the  paroxysm,  we  shall  find  a  positive  and  char- 
acteristic connection  existing  between  the  severity  of  the  attack  and 
certain  physical  signs  in  the  lungs.  We  can  clearly  divide  the  par- 
oxysms into  three  stages,  each  stage  characterized  by  positive  physical 
signs,  and  with  each  stage  a  certain  increasing  degree  of  thf  severity  of 
the  symptom  is  noted. 


112     GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA. 


The  first  stage  may  be  called  the  state  of 

Inspiratory  Dyspncea. 

On  examination  we  find  the  percussion  sound  unaltered ;  on  auscul- 
tation the  inspiratory  sound  of  the  vesicular  murmur  is  replaced  by  a  It  igk- 
pitched,  prolonged  blowing  sound.  The  expiratory  sound  may  be  absent 
or  unchanged.  This  blowing  inspiration  is  evidently  a  blowing  rale,  and 
it  is  caused  by  a  cylindrical  narrowing  of  the  lumen  of  the  bronchi,  not 
sufficient  to  cause  the  sibilant  or  whistling  rales.  It  is  pathognomonic 
of  the  first  stage  of  uncomplicated  asthma,  and  differs  from  the  rough 
inspiratory  murmur  of  bronchitis  or  the  intensified  inspiration  of  the 
exaggerated  respiration  such  as  is  heard  in  compensatory  breathing  or 
in  the  nervous  dyspnoea  of  hysteria  or  blood  poisoning. 

When  asthma  is  complicated  with  bronchitis,  this  inspiratory  blowing 
sound  loses,  in  a  measure,  its  distinctive  quality  and  becomes  rougher  and 
of  lower  pitch.  When  emphysema  is  present,  the  blowing  quality  of  the 
sound  is  less  marked,  and  it  becomes  much  weakened  and  in  some  cases 
is  absent. 

The  symptoms  of  the  first  stage  are  often  slight ;  at  times  wanting. 
In  some  a  slight  tightness  of  the  chest  is  experienced ;  in  others  a  slight 
dyspnoea  is  felt  on  exertion ;  a  paroxysmal  cough  most  marked  in  the 
early  morning  hours  is  sometimes  the  only  symptom. 

The  second  stage  may  be  called  the  stage  of 

Expiratory  Dyspnoea. 

It  presents  the  physical  signs  usually  recognized  as  characteristic  of 
the  asthmatic  paroxysm.  Percussion  gives  an  increased  resonance.  On 
auscultation,  a  prolonged  expiration  is  heard.  Both  expiration  and  in- 
spiration may  be  covered  by  the  sibilant  and  sonorous  rales.  In  certain 
cases  small  moist  rales  of  a  liquid  character  are  heard  over  limited 
portions  of  the  chest.  The  symptoms  of  the  second  stage  are  those 
usually  associated  with  the  asthmatic  paroxysms ;  the  sense  of  oppres- 
sion, the  dyspnoea,  and  the  slow,  labored  breathing  are  marked.  The 
thorax  heaves  with  each  inspiration  and  the  accessory  muscles  of  respi- 
ration are  brought  into  action,  the  patient  is  unable  to  lie  down,  but  sits 
or  moves  in  a  fixed  position,  with  raised  shoulders  and  head  projected 
forward.    The  face  is  livid  and  the  alse  nasi  dilated. 

The  third  stage  may  be  called  the 

Stage  of  Orthopnoea. 

Percussion  gives  a  deep,  drum-like  resonance,  showing  the  extreme 
distention  of  the  vesicles.  On  auscultation  a  short  inspiratory  whiff  is 
heard,  and*the  expiratory  sound  is  inaudible.  The  inspiratory  whiff  is 
most  apparent  over  the  larger  bronchi.     The  symptoms  of  the  third 


GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA.  113 


stage  of  asthma  present  a  picture  of  the  most  supreme  distress  and 
agony.  The  patient  stands  with  the  hands  resting  on  some  fixed  point 
of  support,  and  the  entire  energy  of  the  body  is  given  up  to  the  struggle 
for  air.  The  true  respiratory  muscles  seem  to  be  completely  inactive, 
and  breathing  is  carried  on  entirely  by  the  accessory  muscles  of  respira- 
tion. The  thorax  is  fully  distended  with  little  perceptible  movement; 
the  face  becomes  dusky,  covered  with  perspiration — in  strong  contrast 
with  the  cold  extremities;  a  sense  of  constriction  is  experienced  around 
the  body  over  the  diaphragm. 

These  three  stages  are  evidently  produced  by  the  varying  and 
gradually  lessening  calibre  of  the  bronchial  tubes.  In  the  first  stage  the 
calibre  of  the  tubes  is  not  sufficiently  narrowed  to  produce  the  whistling 
rales.  The  inspiratory  blowing  rale  heard  in  this  stage  is  due  to  the 
moderate  narrowing  of  the  bronchi.  A  normal  inspiration  is  the  result 
of  atmospheric  pressure ;  the  thorax  is  enlarged  by  the  action  of  the 
thoracic  muscles  and  the  diaphragm,  aud  the  lungs  are  distended  by  the 
atmospheric  pressure.  The  expiration  is  mainly  performed  by  the  lung 
vesicles.  In  the  first  stage  the  calibre  of  the  bronchi  is  narrowed,  but 
the  walls  of  the  vesicles  remain  intact  and  are  normal :  hence  the  ex- 
piratory sound  is  normal,  but  the  inspiration  assumes  the  peculiar  high- 
pitched  blowing  found  in  this  stage.  In  the  second  stage  portions  of  the 
bronchi  are  narrowed  to  such  a  degree  that  the  respiratory  sounds 
assume  the  form  of  rales — the  sonorous  and  whistling.  The  vesicles  are 
distended  through  imperfect  ventilation  of  the  lungs  and  the  energy  of 
the  stretched,  elastic  fibres  is  impaired.  The  result  of  this  is  a  pro- 
longed and  labored  expiration,  in  which  the  expiratory  sound  is  formed 
by  the  sonorous  and  sibilant  rales.  In  the  third  stage  the  lumen  of  the 
bronchi  is  reduced  to  a  minute  canal.  The  vesicles  are  distended  to 
their  utmost  capacity ;  the  bronchial  mucous  membrane  is  greatly 
swollen,  and  the  diaphragm  is  either  in  a  state  of  spasm  or  fixed  and 
crowded  by  the  over-distended  lung.  The  greater  portion  of  the  air 
within  the  lung  is  residual  air  and  there  is  no  current  except  in  the 
bronchi  of  larger  calibre ;  aeration  is  performed  slowly  by  the  inter- 
change of  gases  in  this  portion  of  the  lung.  There  is  no  action  of  the 
vesicles  or  the  diaphragm,  and  no  expiration  is  heard;  the  inspiratory 
sound  is  produced  by  the  passage  of  air  through  the  glottis  and  larger 
bronchi.  In  some  cases  we  can  also  see  transition  periods  in  which  the 
first  stage  is  verging  into  the  second — shown  by  the  presence  of  inspira- 
tion commencing  with  a  blowing  rale  and  ending  in  a  sibilant ;  or  with 
a  blowing  rale  on  inspiration  and  a  sibilant  or  sonorous  rale  on  ex  pi  ra- 
tion. The  transition  of  the  second  to  the  third  stage  is  seen  in  shortened 
expiratory  rales  which  disappear  completely  as  it  lapses  into  the  full 
third  stage. 

These  different  stages  of  asthma  occur  in  the  same  individual  at 

NO.  CLXXXV1I. — JULY,  1887.  S 


114     GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA. 

different  times,  although  a  certain  similarity  of  type  is  apt  to  occur  in 
different  individuals.  That  they  are  simply  stages  of  the  same  process, 
and  that  the  varying  physical  sounds  are  all  due  to  a  narrowing  of  the 
bronchi,  are  fully  proven  by  the  effects  of  therapeutic  efforts.  For  ex- 
ample, the  inhalation  of  nitrite  of  amy],  or  an  application  of  carbolate  of 
iodine  to  the  larynx,  will  often  instantly  change  the  inspiratory  whiff  of 
the  third  stage  to  the  prolonged  expiration  with  the  sibilant  and  sonorous 
rales  of  the  second.  This  change  is  at  once  realized  by  the  patient  in  a 
loosening  of  the  constriction  of  the  chest,  and  greater  comfort  and  free- 
dom of  breathing.  AVe  can  also,  through  the  same  means,  produce  a 
change  from  the  whistliug  rales  of  the  labored  expiration  of  the  second 
stage  to  the  blowing  rales  of  the  first.  When  the  asthmatic  is  subjected 
to  some  additional  source  of  irritation,  we  find  the  increased  distress  of 
the  patient  explained  by  the  change  from  the  first  to  the  second  stage, 
or  the  second  to  the  third.  Although  the  asthmatic  paroxysm  is  essen- 
tially due  to  a  bronchial  obstruction,  we  find  it  quite  frequently  inter- 
changeable, and  at  times  complicated  with  spasm  of  the  glottis  and 
spasm  of  the  diaphragm.  In  one  case,  of  a  lady  sixty  years  of  age,  I 
have  seen  a  pure  asthmatic  spasm  subside  and  followed  in  a  few  days  by  a 
distinct  spasm  of  the  glottis,  with  entire  absence  of  asthmatic  breathing ; 
and  again,  in  her  next  attack,  glottic  and  bronchial  spasm  were  absent, 
and  spasm  of  the  diaphragm  was  present.  At  this  time  a  feeling  of 
intense  constriction  was  felt  over  the  diaphragm,  and  the  breathing  was 
almost  entirely  superior  costal,  -with  a  complete  absence  of  the  asthmatic 
rales.  The  sense  of  constriction  in  the  upper  part  of  the  chest  seen  in 
the  asthmatic,  was  wanting.  In  another  case  I  have  seen  a  true 
asthmatic  paroxysm  complicated,  and  at  times  synchronous,  with  spasm 
of  the  glottis.  In  this  case  the  asthma  disappeared,  but  the  man  died 
suddenly  from  glottic  spasm.  These  conditions  cannot  be  considered  in 
reality  as  part  of  asthma,  although  often  complicating  it.  They  bear 
the  same  relation  to  the  asthmatic  paroxysm  as  exists  in  many  other  nerve 
disorders.  For  example,  migraine,  epilepsy,  neuralgia,  and  insanity, 
are  all  interchangeable  with  asthma,  and  in  families  showiDg  a  disposition 
to  nerve  disorders  they  may  be  found  in  different  individuals.  That 
bronchitis  and  emphysema  ultimately  arise  as  sequela?  of  asthma,  is 
clearly  probable,  as  the  continued  disturbance  of  the  normal  condition 
of  the  bronchial  mucous  membrane  is  apt  to  produce  and  incite  patho- 
logical changes ;  and  the  great  and  frequent  disturbance  of  the  elastic 
fibres  of  the  vesicle  can  only  result  in  weakening  and  loss  of  tone.  The 
right  ventricle  must  also  frequently  suffer,  undergoing  dilatation  and 
hypertrophy,  as  the  great  distention  of  the  walls  of  the  vesicles  must 
seriously  interfere  with  the  uormal  pulmonary  circulation. 

The  mechanism  by  which  the  asthmatic  paroxysm  is  caused,  has 
always  been  the  subject  of  dispute  and  controversy.    Laennec,  followed 


GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA.  115 

by  Andral,  ascribed  it  to  spasm  of  the  circular  fibres  of  the  bronchi, 
causing  cylindrical  narrowing  of  these  tubes.  This  may  be  said  to  be  the 
prevailing  doctrine  at  the  present  day,  and  it  has  been  endorsed  by  many 
of  the  most  eminent  authorities  in  medicine;  among  these  may  be  men- 
tioned the  names  of  C.  J.  B.  Williams,  Bergson,  Hyde  Salter,  Trous- 
seau, and  Biermer.  Rieseisen  having  demonstrated  the  existence  of  the 
circular  fibres  of  the  bronchi,  others  have  sought  to  prove  their  capa- 
bility of  contraction  under  certain  stimuli.  Longet  and  Volkmann 
especially  claim  to  have  accomplished  this  by  means  of  electro-stimula- 
tion of  the  vagus,  but  this  result  has  not  been  produced  when  the 
experiments  have  been  carried  out  by  others.  The  theory  of  bronchial 
spasm  as  an  element  of  the  asthmatic  paroxysm,  has  been  warmly  dis- 
puted. Budd  rejected  the  idea,  and  he  has  been  followed  by  Wintrich, 
Bamberger,  Germain  See,  and  others.  Duchenne  having  demonstrated 
that  faradization  of  the  phrenic  nerve  caused  spasm  of  the  diaphragm, 
was  inclined  to  consider  this  as  an  essential  element  of  the  paroxysm. 
In  this  he  was  supported  by  Wintrich  and  Bamberger.  Traube  denied 
the  nervous  origin  of  asthma,  and  ascribed  the  dyspnoea  to  the  fluctionary 
hyperemia  of  the  bronchial  mucous  membrane.  He  supposed  certain 
persons  to  have  a  certain  predisposition  to  asthma,  and  that  the  predis- 
position consisted  in  a  deficiency  of  the  elastic  fibre  in  the  lung,  allow- 
ing a  ready  distention  of  the  bloodvessels,  and  thus  allowing  a  ready 
swelling  of  the  bronchial  mucous  membrane.  Sanderson  ascribes  the 
paroxysm  to  a  dependency  on  a  change  in  the  respiratory  function  of 
the  vocal  cords.  He  believes  this  to  be  an  extreme  relaxation  of  the 
vocal  cords  during  slumber,  and  a  narrowing  of  the  rima  glottidis.  Beau 
considers  asthma  to  be  a  bronchial  catarrh  with  viscid  secretions.  Ley- 
den  ascribes  the  attack  to  be  due  to  the  presence  in  the  bronchi  of  a 
peculiar  kind  of  octahedral  crystals  produced  from  white  blood-corpus- 
cles, which  irritate  the  pulmonary  filaments  of  the  vagus,  and  provoke 
the  bronchial  spasm.  Weber  considers  asthma  to  be  a  vasomotor  neu- 
rosis in  which  an  acute  catarrh  with  a  dilatation  of  the  vessels  of  the 
bronchial  mucous  membrane  is  produced.  In  this  theory  he  has  been 
followed  by  Storck,  who  asserts  the  existence  of  tracheal  congestion  as 
shown  by  the  laryngoscopic  mirror.  Lately,  Sir  Andrew  Clark  has 
described  a  condition  of  the  bronchial  mucous  membrane  simulating  the 
wheals  of  urticaria  on  the  skin,  and  has  sought  to  prove  this  to  be  a 
pathological  condition  of  the  disorder. 

That  the  theory  of  spasm  of  the  bronchial  muscles  is  the  prevailing 
one  must  be  admitted,  but  it  stands  more  in  the  light  of  medical  tradi- 
tion than  proven  fact.  The  experiments  made  to  prove  the  contract*- 
bility  of  the  bronchial  fibres  by  irritation  of  the  vagus  have  beeu  con- 
flicting, and  the  uritenability  of  the  theory  has  been  notably  disproved, 
both  on  clinical  and  experimental  grounds,  by  Wintrich  and  Germain 


116     GLASGOW,  ETIOLOGY  AND   MECHANISM  OF  ASTHMA. 

See.  The  fact  of  the  circular  fibres  being  of  the  unstriped  variety,  in 
which  the  contraction  must  be  slow  and  gradual,  absolutely  negatives 
their  cooperation  in  the  sudden  and  transient  narrowing  necessary  to 
produce  the  phenomena  of  asthma.  The  office  of  the  bronchial  muscles 
seems  more  probably  to  be  that  of  supporting  muscles,  regulating  and 
supporting  the  bronchi  against  atmospheric  pressure  and  undue  violence 
of  exertion.  The  recent  experiments  of  Riegel  and  Edinger  haye  shown 
conclusively  that  irritation  of  the  vagus  does  not  provoke  a  bronchial 
spasm,  but  rather  a  spasm  of  the  diaphragm ;  Biermer,  the  earnest 
defender  of  the  theory  of  bronchial  contractibilitv,  is  forced  to  say 
that  although  stimulation  of  the  vagus  may  not  produce  marked  con- 
tractions of  the  bronchial  muscles,  we  have  not  yet  found  the  proper 
experiments  necessary  to  prove  it,  and  possibly  the  stimulation  must  be 
to  the  pulmonary  sympathetic  plexus  rather  than  to  the  vagus.  That 
spasm  of  the  glottis  and  spasm  of  the  diaphragm  occur  in  the  asthmatic 
cannot  be  denied  by  any  one  who  has  made  a  study  of  the  disorder ;  the 
symptoms  of  those  conditions  are  so  marked,  and  their  occurrence  so 
frequent,  that  they  cannot  be  overlooked;  but  that  they  are  part  of  the 
essential  nature  of  asthma  is  not  true,  as  we  find  many  cases  of  asthma 
in  which  they  are  wanting.  Spasm  of  the  diaphragm  can  never  produce 
the  mechanical  rales  always  found  in  asthma,  although  in  certain  cases 
it  may  play  an  important  part  in  producing  the  great  distention  of  lung 
vesicles  seen  in  the  later  stage  of  the  disease.  The  theory  of  Weber, 
that  the  paroxysm  is  due  to  vasomotor  turgescence  or  dilatation  of  the 
mucous  membrane  of  the  bronchi,  finds  complete  support  in  the  clinical 
picture  of  asthma :  the  transient  and  rapid  variations  of  the  physical 
sounds,  the  presence  of  the  dry  and  moist  rales,  and  the  acute  distention 
of  the  lungs  seen  in  pronounced  attacks  of  the  disease.  This  theory, 
however,  is  directly  contradictory  to  the  acknowledged  physiological 
effect  of  the  drugs  which  are  generally  recognized  as  most  useful  in 
allaying  the  paroxysm;  the  nitrites,  chloral,  and  morphia  are  all 
known  as  relaxants  and  anti-spasmodics,  and  their  use  could  only  in- 
crease the  distress  if  the  dyspnoea  was  due  to  a  vasomotor  dilatation 
of  the  vessels  of  the  bronchial  mucous  membrane.  The  action  of 
chloral  and  morphine  could  be  explained  by  their  effect  on  the  nerve- 
centres  ;  but  the  efficacy  of  the  nitrites  finds  here  no  support.  The 
physiological  action  of  venous  blood  and  carbonic  acid  on  the  arterioles 
and  their  actual  effect  in  asthma  negative  the  existence  of  a  vasomotor 
dilatation  of  the  arterioles  as  a  cause  of  the  paroxysm.  Ludwig  and 
Severini  have  shown  that  venous  blood,  when  circulated  for  a  length  of 
time,  causes  the  vessels  to  dilate,  and  that  a  large  amount  of  carbonic 
acid  in  the  blood  causes  a  dilatation  of  the  vessels.  The  natural  sequence 
of  an  asthmatic  paroxysm  is  extreme  venosity  of  the  blood,  with  an 
accumulation  of  carbonic  acid  through  its  imperfect  aeration.  These 


GLASGOW,  ETIOLOGY  AND  MECHANISM  OF  ASTHMA.  117 

conditions  in  reality  existing  to  such  an  extreme  degree  in  the  asthmatic 
paroxysm,  would  simply  increase  the  paroxysm  if  the  disturbance  were 
due  to  vasomotor  paralysis  of  the  vessels ;  whilst,  in  fact,  we  find  them 
to  be  essential  elements  in  the  natural  cessation  of  the  attack. 

In  a  paper  read  before  the  American  Laryngological  Society,  at 
Detroit,  in  1885,  I  described  a  condition  of  the  nasal  mucous  membrane 
seen  in  certain  patients.  This  condition  is  characterized  by  pallor, 
swelling,  and  an  oedematous  condition  of  the  membrane.  When  irritated 
as  by  the  touch  of  a  probe  or  any  other  irritant,  the  swelling  is  increased 
and  a  profuse,  thin  or  watery  secretion  is  poured  out.  This  condition 
promptly  subsides  after  the  inhalation  of  nitrite  of  amyl,  ether,  or  the 
instillation  of  atropine  or  morphia;  but  remains  unchanged  on  the 
application  of  cocaine.  These  cases  occurred  in  persons  of  a  marked 
nervo-vascular  temperament,  and  in  whom  functional  nerve  disturbances 
were  common.  The  existence  of  pallor,  more  or  less  marked,  and  a 
marked  oedematous  condition  of  the  mucous  membrane,  distinguish 
this  condition  from  that  ordinarily  seen  in  vasomotor  catarrh.  In  the 
latter  condition  there  is  hyperemia  with  dilatation  of  the  vessels ;  but 
in  the  former  the  pallor  completely  negatives  the  idea  of  a  dilated  con- 
dition of  the  vessels,  and  the  opposite  condition  must  exist.  The  action 
of  the  drugs  indicated  in  these  cases  rather  a  spasm  of  the  arterioles, 
and  I  have  chosen  to  consider  the  disturbance  of  the  nasal  membrane  to 
be  due  to  a  vasomotor  spasm  of  the  arterioles  of  the  membrane.  The 
following  case,  in  which  this  peculiar  condition  was  the  accompaniment 
of  a  facial  neuralgia,  is  presented  as  a  perfect  type  of  the  condition : 

A.  M.,  merchant,  florid,  stout,  about  forty-five  years  of  age,  was 
brought  to  me,  complaining  of  facial  neuralgia  of  the  left  side  and  great 
obstruction  in  the  nostril  of  that  side.  He  said  that  this  obstruction  of 
the  nostril  had  occurred  simultaneously  with  the  attack  of  the  neuralgia ; 
that  at  times  it  was  so  great  as  completely  to  close  the  canal.  There  was 
a  profuse  discharge  of  a  thin,  limpid  fluid,  which  was  greatly  increased 
on  the  application  of  any  irritant,  such  as  dust,  or  the  touch  of  the 
probe.  These  same  agents  also  had  a  marked  effect  in  increasing  the 
swelling  of  the  cavernous  tissue.  On  inspection  the  right  nostril  was 
found  normal ;  the  left  nostril  was  almost  completely  occluded  by  the 
pallid  membrane  of  the  swollen  cavernous  bodies,  almost  as  pale  as 
that  seen  in  a  corpse.  It  presented  an  oedematous,  boggy  appearance, 
as  if  the  whole  tissue  was  saturated  with  secretion,  and  on  any  irritation 
this  was  poured  out  in  a  profuse  discharge  of  a  thin,  limpid  character. 
This  entirely  subsided  with  a  subsidence  of  the  facial  neuralgia, 

A  study  of  these  cases  led  me  to  surmise  that  possibly  an  analogous 
condition  may  exist  in  the  mucous  membrane  of  the  bronchi  during 
asthmatic  attacks.  I  examined  a  large  number  of  asthmatics  during 
the  paroxysm  with  the  laryngoscope  mirror,  and  found  that  during  the 
paroxysms  the  mucous  membrane  of  the  pharynx,  including  the  uvula, 
presented  a  similar  pallid,  oedematous  appearance;  that  the  membranes 


118 


TRUDEAU,  ETIOLOGY  OF  TUBERCULOSIS. 


of  the  larynx  and  trachea  appeared  paler  and  more  swollen  than  nor- 
mal, but  not  so  (Edematous  as  that  of  the  pharynx.  When  portions  of 
the  membrane  were  inflamed,  as  is  common  in  asthma,  the  inflamed  area 
presented  more  the  pale  red  of  an  intensely  anaemic  or  phthisical  subject 
than  the  rosy  red  of  ordinary  hyperemia  or  inflammation.  This  is  in 
direct  contradiction  to  the  observation  of  Storck,  who  claims  to  have 
found  the  larynx  and  trachea  congested  during  the  attack.  If  these 
conditions  can  be  seen  to  exist  during  the  asthmatic  paroxysms  in  the 
upper  air-passages  as  far  as  inspection  is  possible,  I  think  we  are  fully 
justifiable  in  reasoning  that  an  analogous  condition  exists  in  the  bronchi. 
The  normal  functional  differences  between  the  mucous  membrane  of  the 
bronchi  and  that  of  the  upper  air-passages  would  somewhat  change  the 
picture,  more  especially  as  the  excessive  glandular  secretions  would  be 
greatly  diminished  in  quantity  or  even  wanting.  A  similar  condition  to 
this  we  find  existing  in  the  sympathico-tonica  type  of  migraine  (Eulen- 
burg),  with  vascular  spasm  and  diminished  supply  of  blood  in  the  brain. 

I  would,  then,  consider  asthma  to  be  a  disorder  of  vascular  irritability ; 
that  the  paroxysm  is  directly  due  to  a  partial  occlusion  or  cylindrical 
narrowing  of  the  lumen  of  the  bronchi  through  the  swelling  of  the 
bronchial  mucous  membrane;  that  this  swelling  is  caused  by  a  vasomotor 
spasm  of  the  arterioles  with  a  saturation  of  the  tissues  by  the  liquor 
sanguinis ;  this  condition  is  accompanied  by  a  general  high  blood 
pressure. 

With  this  theory  we  find  a  complete  explanation  of  all  the  physical 
signs  of  asthma.  We  see  the  possibility  of  the  rapid  changes  of  physical 
signs  observed  during  the  paroxysms,  and  we  have  in  its  support  the 
physiological  action  of  all  the  drugs  which  experience  proves  to  be  of 
value  in  allaying  the  paroxysm — the  nitrite  of  amyl,  morphia,  chloral, 
lobelia,  and  iodide  of  potash  in  their  action  allay  the  spasm  at  the  same 
time  that  they  tend  to  reduce  general  blood  pressure ;  whilst  drugs  like 
the  bromides  prove  of  little  value  in  breaking  the  paroxysms  when  once 
in  force,  although  they  are  serviceable  in  preventing  a  recurrence. 


ENVIRONMENT  IN  ITS  RELATION  TO 
THE  PROGRESS  OF  BACTERIAL  INVASION  IN  TUBERCULOSIS. 

By  E.  L.  Tetjdeatj,  M.D., 

OF  SAEAJfAC  LAKE,  N.  Y. 

Though  much  light  has  been  thrown  of  late  on  the  etiology  of  tuber- 
culosis by  the  labors  of  Koch,  Baumgarten,  Weigert,  and  others,  the 
conditions  which  lead  to  tubercular  infection  are  yet  shrouded  in 


TKUDEAU,  ETIOLOGY  OF  TUBERCULOSIS. 


119 


mystery,  and  many  clinical  facts  and  teachings  remain  seemingly  at 
variance  with  the  new  doctrine.  The  older  clinical  medicine  on  one 
side  points  to  unhygienic  surroundings,  malnutrition,  struma,  defect  of 
anatomical  structure,  and  heredity  as  the  main  causes  of  tubercular 
disease,  while  experimental  research  brings  evidence  not  easily  to  be 
thrust  aside  to  support  its  claim  to  have  discovered  in  the  bacillus  tuber- 
culosis the  virus  which  is  essential  to  the  production  of  this  fatal  class 
of  maladies. 

The  acknowledged  causes  of  consumption  may  conveniently  be 
divided  into  those  operating  before,  and  after  birth,  the  former  coming 
under  the  general  heading  of  heredity,  the  latter  of  environment.  The 
problems  of  heredity  are  most  complex  and  reach,  as  yet,  far  into  the 
domain  of  hypothesis ;  but  the  effect  of  environment  in  its  relation  to 
bacillary  invasion  may  more  readily  be  subjected  to  study.  So  much  do 
certain  conditions  of  air,  light,  food,  and  especially  habitation  influence 
the  etiological  history  of  the  development  of  consumption  that  a  predic- 
tion as  to  the  prevalence  of  the  disease  in  any  given  locality  may  often 
be  based  on  a  thorough  knowledge  of  these  conditions.  Drs.  Bowditch 
and  Pepper1  in  this  country,  and  Dr.  Buchman2  in  England,  have  done 
most  valuable  work  in  this  direction  and  the  results  of  their  labors  alone 
seem  sufficient  to  establish  the  fact  that  environment  is  a  most  potent 
factor  in  the  causation  of  tuberculosis.  What,  however,  are  its  rela- 
tions, if  any,  to  the  development  and  progress  of  bacillary  invasion  ? 
To  determine  how  far  extremes  of  environment  favor  or  arrest  the 
progress  of  germ  infection  and  to  what  degree  they  are  mutually  or 
independently  concerned  in  the  causation  of  tuberculosis,  has  been  the 
object  of  this  research  and  an  answer  to  the  three  following  questions 
sought. 

First.  What  results  ensue  when  both  bacillary  infection  and  unhygienic 
surroundings  are  made  to  coexist  in  tuberculosis? 

Second.  Are  unhygienic  surroundings,  when  every  known  precaution 
has  been  taken  to  exclude  the  bacillus,  sufficient  of  themselves  to  bring 
about  the  disease  ? 

Third.  Is  bacillary  infection  invariably  progressive  in  animals  placed 
under  the  best  conditions  of  environment  attainable  ? 

Experiments. — Fifteen  rabbits  were  made  use  of  and  divided  in 
three  lots,  each  set  of  animals  being  placed  under  conditions  best  adapted 
to  answer  in  the  results  noted  the  three  questions  already  referred  to. 

Experiment  No.  1.  Five  rabbits  were  inoculated  in  the  right  lung  and 
in  the  left  side  of  the  neck  with  five  minims  of  sterilized  water  in  which 
was  suspended  a  sufficient  quantity  of  a  pure  culture  (third  generation) 
of  the  tubercle  bacillus  to  render  the  liquid  quite  perceptibly  turbid. 

1  New  York  Medical  Journal,  Dec.  4,  1886. 

2  Ninth  and  Tenth  Report,  Medical  Officer,  Trivy  Council,  C5-G7. 


120 


TRUDEAU,    ETIOLOGY   OF  TUBERCULOSIS. 


The  needle  of  the  Koch's  inoculating  syringe  was  inserted  subcu- 
taneously  on  the  left  side  of  the  neck  and  in  the  third  intercostal  space 
to  a  depth  of  thirty  millimetres  on  the  right  side.  These  animals  were 
then  confined  in  a  small  box  and  put  in  a  dark  cellar.  They  were  thus 
deprived  of  light,  fresh  air,  and  exercise,  and  were  also  stinted  in  the 
quantity  of  food  given  them  while  being  themselves  artificially  infected 
with  the  tubercle  bacillus. 

Experiment  No.  2.  Five  healthy  rabbits  were  placed  under  the  follow- 
ing conditions :  A  fresh  hole  about  ten  feet  deep  was  dug  in  the  middle 
of  a  field,  and  the  animals  having  been  confined  in  a  small  box  with 
high  sides  but  no  top,  were  lowered  to  the  bottom  of  this  pit,  the  mouth 
of  which  was  then  covered  with  boards  and  fresh  earth.  Through  this 
covering  a  small  trap  door  was  cut  which  was  only  opened  long  enough 
each  day  to  allow  of  the  food,  consisting  of  a  small  potato  to  each 
rabbit,  being  thrown  to  the  animals.  So  damp  wTas  the  ground  at  the 
bottom  of  this  pit  that  the  box  in  which  the  rabbits  were  confined  was 
constantly  wet.  Thus  these  animals  were  deprived  of  light,  fresh  air, 
and  exercise,  furnished  with  but  a  scanty  supply  of  food  while  breathing 
a  chill  and  damp  atmosphere,  though  free  from  disease  themselves  and 
removed  as  far  as  possible  from  any  accidental  source  of  bacterial 
infection. 

Experiment  No.  3.  Five  rabbits  having  been  inoculated  in  precisely 
the  same  manner  as  the  animals  in  the  first  experiment,  were  at  once 
turned  loose  on  a  small  island  in  June,  1886.  It  would  be  difficult  to 
imagine  conditions  better  suited  to  stimulate  the  vitality  of  these  animals 
to  the  highest  point  than  were  here  provided.  They  lived  all  the  time 
in  the  sunshine  and  fresh  air,  and  soon  acquired  the  habit  of  constant 
motion  so  common  in  wild  animals.  The  grass  and  green  shrubs  on  the 
island  afforded  all  the  fresh  food  necessary  and  in  addition  they  were 
daily  provided  with  an  abundant  supply  of  vegetables.  Thus,  while 
artificially  infected  themselves  they  were  placed  in  the  midst  of  condi- 
tions well  adapted  to  stimulate  their  vital  powers  to  the  highest  point 
attainable. 

Results. — Experiment  No.  1.  Four  of  the  inoculated  rabbits  confined 
in  the  cellar  died  within  three  months :  in  all  of  them  the  injected  lung 
was  extensively  diseased ;  the  other  lung  and  the  bronchial  glands  being 
also  more  or  less  involved  and  tubercles  in  various  stages,  but  sufficiently 
advanced  to  be  macroscopical,  were  found  in  the  pleura,  peritoneum, 
spleen,  and  liver;  from  these  lesions  pure  cultures  of  tubercle  bacilli 
were  obtained.  The  fifth  rabbit  survived  and  was  killed  four  months 
after  injection ;  at  the  autopsy  the  right  lung  was  found  solidified  and 
shrivelled,  the  upper  portion  being  almost  entirely  destroyed,  while  a 
bronchial  gland  as  large  as  a  hazelnut,  filled  with  creamy  pus,  occupied 
the  right  chest ;  tubercles,  which  in  many  places  had  become  cheesy, 
studded  the  upper  portion  of  the  left  lung.  The  other  organs  were 
healthy. 

Experiment  No.  2.  The  five  uninoculated  and  healthy  rabbits  placed 
in  the  damp  pit  were  all  living  at  the  end  of  four  months.  They  were 
emaciated  and  theii  coats  were  rough,  but  they  still  seemed  about  as 
active  as  at  the  beginning  of  the  experiment.  They  were  all  killed 
within  a  few  days  of  each  other,  but  a  careful  examination  of  their 
organs  revealed  nothing  abnormal  in  any  of  them. 


TRUDEAU,  ETIOLOGY  OF  TUBERCULOSIS.  121 

Experiment  No.  3.  One  of  the  five  rabbits  which  were  allowed  to  run 
at  large  died  just  one  month  after  inoculation.  The  lower  portion  of 
the  lung  was  solidified,  the  bronchial  glands  enlarged,  as  well  as  the 
axillary  glands  on  the  left  side,  and  a  few  tubercles  were  made  out  in  the 
spleen.  The  left  lung  and  all  the  other  organs  were  sound.  The  four 
other  rabbits  remained  apparently  in  perfect  health,  and  so  active  had 
they  become  that  two  of  them  could  only  be  captured  with  the  aid  of  a 
gun.  All  four  animals  were  killed  at  the  beginning  of  November,  or 
four  months  after  inoculation.  They  were  loaded  with  adipose  tissue 
and  their  flesh  was  so  firm  and  red  as  to  be  in  striking  contrast  to  the 
blanched  and  flabby  muscles  of  the  other  rabbits  previously  examined. 
All  the  organs  were  healthy  and  even  the  points  of  inoculation  could 
not  be  made  out. 

A  review  of  the  evidence  afforded  by  these  experiments  confirms  the 
view  that  the  production  of  tuberculosis  is  a  most  complex  problem  and 
one  in  which  many  elements  besides  the  bacillus  enter.  How  surely 
and  rapidly  this  microbe  accomplishes  its  work  when  the  normal  resisting 
power  of  the  system  is  for  any  cause  lowered,  is  well  shown  by  the 
manner  in  which  the  first  lot  of  animals  succumbed.  Localized  tuber- 
culosis was  in  every  instance  but  one  quickly  folloAved  by  general 
systemic  infection  and  death.  That  animals  kept  in  most  laboratories 
are  frequently  confined  under  conditions  of  air,  light,  and  overcrowding, 
which  may  materially  influence  the  results  of  investigations  in  a  disease 
of  the  nature  of  tuberculosis,  can  hardly  be  denied  and  should  be  kept 
in  view. 

Necessarily  imperfect  so  far  as  affording  protection  from  bacillary 
infection  as  were  the  conditions  under  which  the  animals  in  Experiment 
No.  2  were  placed,  the  results  obtained  seem  to  indicate  that  unfavorable 
environment  and  the  consequent  malnutrition  which  invariably  follows 
existence  amidst  unhygienic  surroundings  are  not  sufficient  of  them- 
selves to  cause  tuberculosis.  The  fate  of  the  animals  allowed  to  run 
wild  is  most  instructive,  inasmuch  as  it  seems  to  indicate  that  in  a  great 
majority  of  instances  resistance  to  the  invasion  of  so  deadly  a  germ  as 
the  tubercle  bacillus  is  possible  in  the  artificially  produced  disease,  pro- 
vided the  vital  and  nutritive  processes  of  the  animal  are  stimulated  to 
the  highest  possible  state  of  activity. 

.  In  estimating,  however,  the  power  of  environment  in  rendering  these 
rabbits  insusceptible  to  the  disease,  it  must  be  remembered  that  in  them 
the  tuberculosis  was  an  artificial  one,  produced  in  previously  sound  ani- 
mals, and  not  the  culmination,  as  in  the  spontaneous  disease  in  man  and 
animals  of  many  debilitating  causes,  acting  often  through  long  periods 
of  time,  and  impairing  the  resisting  power  of  the  system  to  such  a 
degree  as  to  allow  of  spontaneous  infection.  That  incipient  phthisis  is 
frequently  recovered  from  is  demonstrated  by  the  results  of  autopsies  on 
individuals  dying  from  other  causes,  and  by  a  long  list  of  clinical 
observations.   The  interesting  cases  of  tubercular  inoculation  in  circum- 


122 


TRUDEAU,  ETIOLOGY  OF  TUBERCULOSIS. 


cised  children  recently  reported  by  Lehman,1  furnish  proof  that  so 
large  a  number  as  thirty  per  cent,  of  recoveries  may  occur,  after  artificial 
inoculation,  even  when  profound  systemic  infection  has  existed.  Experi- 
mental research  has  already  furnished  proof  of  the  potency  of  environ- 
ment in  determining  microbic  diseases  in  animals  otherwise  insusceptible. 
Thus,  Pasteur2  succeeded  in  killing  hens  with  anthrax,  after  reducing 
their  naturally  high  temperature  by  keeping  them  partially  immersed 
in  cold  water,  though  these  birds  in  their  usual  surroundings  are  proof 
against  this  microbe.  Gibier3  gave  the  same  disease  to  fish,  and  Metz- 
chinkoff4  to  frogs,  by  warming  the  water  in  which  they  lived,  after  fail- 
ing to  infect  them  in  their  natural  environment.  Wild  animals  and 
game  birds,  which,  in  their  wild  state,  are  never  known  to  die  of  tubercu- 
losis, rapidly  succumb  to  the  malady  when  placed  in  confinement,  and 
the  North  American  Indians,  among  whom  phthisis  is  practically 
unknown  while  living  a  savage  life,  are  decimated  by  consumption  when 
placed  under  the  trying  restrictions  of  a  more  civilized  mode  of  exist- 
ence. 

If,  therefore,  environment  is  so  potent  a  factor  in  determining  bacterial 
infection,  are  its  effects  on  the  future  course  of  the  malady  when  it  has 
occurred  to  be  disregarded  ?  How  potent  may  be  its  influence  is  demon- 
strated by  the  widely  differing  results  obtained  in  the  inoculated  rabbits 
allowed  to  run  wild,  and  those  confined  amidst  unhygienic  surroundings. 
That  it  is  not,  however,  more  than  a  predisposing  cause  of  the  disease, 
seems  indicated  by  the  survival  of  the  animals  in  Experiment  No.  2, 
which,  though  they  were  deprived  of  fresh  air,  light,  and  exercise,  and 
stinted  in  the  amount  and  quality  of  their  food  for  over  three  months, 
developed  no  organic  lesions.  Thus  it  would  seem  that  the  local  mischief 
having  been  produced,  the  future  type  assumed  by  the  morbid  pro- 
cesses, and  even  the  ultimate  result,  is  greatly  dependent  on  the  resisting 
power  evinced  by  the  individual,  which  may  be  computed  as  the  sum 
total  of  all  the  conditions  which  affect  individual  vitality  through 
heredity  and  environment. 

The  two  ultimate  elements  in  this  struggle  for  existence  are  the  bacil- 
lus and  the  cell.  Though  in  its  infancy,  bacteriology  already  points  to 
the  cell  as  an  active  factor  in  resisting  the  progress  of  bacterial  invasion. 
Metzchinkoff5  saw  the  lymph  cells  of  the  frog  englobe  and  destroy 
anthrax  bacilli,  and  Wyssokowitsch6  found  the  microbes  which  he 
injected  in  the  circulation  of  animals,  taken  up  by  the  endothelial  cells 
lining  the  capillaries  of  various  organs,  where  they  finally  became 
destroyed.    Suppuration  is  now  being  looked  upon  by  some  as  a  con- 

1  Deutscli.  mod.  Wochensch.,  1886,  Nos.  9-13. 

2  Les  Bacteries,  Cornil  and  Babes,  page  582.  3  Ibid.,  page  581. 

4  Virchow's  Arcbiv,  vol.  xlviii.  p.  503.  5  Virchovv's  Archiv,  vol.  xlviii.  p  503. 

6  Ueber  die  Shicksal  der  ins  blut  injicerten  Mikrobrganisni.    Zeitschrift  fur  Hygiene,  Bd.  i.  Heft  1. 


MACEWEN,  PUPIL  IN  ITS  SEMEIO LOGICAL  ASPECTS.  123 


servative  process  in  which  the  leucocytes  are  thrown  out  in  great  num- 
bers, to  destroy  bacteria,  and  as  a  barrier  to  systemic  infection.  The 
peculiar  relation  of  the  bacilli  to  the  nuclei  in  the  giant  cells  themselves, 
suggests  the  possibility  of  an  antagonism  between  the  two.  As  the 
pathogenic  qualities  of  infectious  germs  may  in  many  instances  be  abro- 
gated or  diminished  at  will,  as  in  the  preliminary  manipulation  of 
bacteria  used  in  vaccinations,  by  placing  them  under  peculiar  condi- 
tions of  environment  which  rob  them  of  their  virulence,  or  modify 
it,  so  may  the  resisting  power  of  their  natural  enemies,  the  cells  of  the 
body,  be  diminished  or  increased  by  the  same  means.  Watson  Cheyne,1 
in  a  review  of  some  of  his  recent  experiments,  after  describing  the 
manner  in  which  large  quantities  of  putrefactive  and  non-pathogenic 
bacteria  are  destroyed  when  injected  into  the  blood-current  of  rabbits, 
adds  "  but  this  does  not  occur  if  the  animal  is  in  a  bad  state  of  health." 

Viewed  in  this  light,  the  teachings  of  clinical  medicine,  the  knowledge 
obtained  by  a  study  of  the  therapeutics  of  the  disease,  and  the  proof 
offered  by  experimental  research,  are  in  perfect  accord.  All  measures 
which  tend  to  increase  the  vitality  of  the  body  cells  have  been  found  to 
be  precisely  those  which  are  most  effectual  in  combating  tuberculosis ; 
one  by  one,  specific  methods  of  treatment,  which  for  a  season  enjoyed 
popularity,  have  fallen  into  disuse,  and  hygiene,  climate,  and  feeding — 
in  other  words,  a  favorable  environment — have  alone  given  results  which 
have  stood  the  test  of  time. 

A  consideration  of  the  evidence  offered  by  this  study,  therefore, 
teaches  that  though  environment  may  bear  but  the  relation  of  a  predis- 
posing cause  to  microbic  infection,  it  is,  nevertheless,  a  potent  factor  in 
determining  the  future  type,  and  even  the  final  results  of  the  disease, 
and  that  if  we  may  not  under-estimate  the  pathogenic  properties  of  the 
bacillus,  the  effect  of  extremes  of  environment  on  the  resisting  power  of 
the  cells  of  the  body  is  an  element  in  this  complex  problem  which  should 
not  be  ignored. 


THE  PUPIL  IN  ITS  SEMEIOLOGICAL  ASPECTS. 
By  William  Macewen, 

SURGEON  TO,  AND  LECTURER  ON  SURGERY,  ROYAL  INFIRMARY,  AND 
SURGEON  TO  CHILDREN'S  HOSPITAL,  GLASGOW. 

Many  observations  have  been  made,  from  numerous  standpoints,  re- 
garding pupillary  conditions,  yet  with  a  few  notable  exceptions,  they 
have  been  studied  in  an  isolated  manner,  relative  to  the  particular  disease1 
or  lesion  of  which  they  might  be  more  or  less  symptomatic.    They  have 


1  Bacteriology.    Amer.  Journ.  Med  Sci.,  January,  1887. 


124     MACE  WEN ,  PUPIL  IN  ITS  SEMEIOLOGICAL  ASPECTS. 

been  often  looked  upon,  and  are  still  regarded  by  some,  as  curious,  in- 
teresting, but  erratic  phenomena,  far  too  variable  to  be  depended  upon, 
and  without  any  connecting  thread  upon  which  these  conditions,  as  seen 
in  a  variety  of  diseases,  could  be  strung.  Few  attempts  have  been  made 
to  grasp  pupillary  manifestations  as  a  whole,  still  fewer  to  reduce  the 
varying  phenomena  to  principles  or  to  reduce  the  laws  by  which  they  are 
controlled. 

Among  the  papers  dealing  with  the  pupil  as  a  whole,  that  of  Dr. 
Alph.  Drouin  is  one  of  the  most  complete,  and  the  writer  is  indebted  to 
that  work  for  information,  especially  from  the  section  devoted  to  anatomy 
and  physiology.  Mr.  Hutchinson's  excellent  papers  on  the  "  Symptom 
Significance  of  Different  States  of  the  Pupil,"  published  in  the  first 
volume  of  Brain,  contain  much  that  is  of  value,  to  which  the  reader's 
attention  is  directed. 

In  the  present  paper  it  is  intended  to  give,  first,  with  the  view  of  re- 
freshing the  mind  of  the  reader,  a  brief  outline  of  the  physiological 
phenomena  pertaining  to  the  movements  of  the  pupil,  and  thereafter  to 
present  a  series  of  personal  observations  from  which  certain  conclusions 
have  been  drawn. 

Physiological  Outline. — The  optic  nerves  have  no  direct  control 
over  the  pupil.  The  impression  produced  by  light  falling  upon  the 
retina  passes  through  the  second  nerves  to  the  corpora  quadrigemina, 
which  communicate  an  impulse  to  the  oculomotor  centres,  and  so  cause 
pupillary  contraction.  The  second  is  thus  the  afferent  nerve  in  this  re- 
flex (excito-motor)  action.  This  reflex  phenomenon  may  be  brought 
about  not  only  by  the  impression  of  light  upon  the  retina,  but  also  by 
mechanical  stimulation  of  the  optic  nerves,  which  induces  in  them  a 
sensation  of  light.  When  both  optic  nerves  are  divided  or  paralyzed, 
dilatation  and  immobility  of  the  pupils  ensue.  Paralysis  of  one  optic 
nerve  produces  dilatation  of  the  pupil  with  blindness  on  the  same  side  as 
the  lesion ;  but  owing  to  the  preservation  of  consensual  movements  the 
pupil  of  the  injured  eye  contracts  when  impressions  of  light  are  made 
upon  the  sound  retina,  though  these  are  quicker  and  stronger  on  the 
sound  side.  Therefore,  pupillary  phenomena  are  sometimes  wanting 
when  only  one  optic  is  paralyzed,  owing  to  the  preservation  of  consensual 
movements ;  in  this  way  it  differs  from  unilateral  lesions  of  the  third, 
which  always  affect  the  corresponding  pupil  in  a  very  definite  way. 
Section  or  destruction  of  one  optic  tract  produces  dilatation  of  the  oppo- 
site pupil,  and  blindness  of  the  opposite  eye. 

The  third  nerve  takes  origin  beneath  the  floor  of  the  aqueduct  of 
Sylvius,  and  supplies  the  ciliary  muscle  and  sphincter  of  the  iris,  besides 
all  the  muscles  of  the  globe  with  the  exception  of  the  external  rectus 
and  superior  oblique.  When  the  third  nerve  is  stimulated  contraction 
of  the  pupil  on  the  same  side  ensues,  and  when  it  is  divided  or  paralyzed 


MACE  WE  N,  PUPIL  IN  ITS  SE  MEI OLOGICAL  ASPECTS.  125 

the  pupil  dilates ;  it  no  longer  responds  to  the  action  of  light,  and  accom- 
modation is  abolished.  When  the  central  portion  of  a  cut  oculomotor 
is  stimulated,  the  opposite  pupil  becomes  contracted,  provided  the  nerve 
on  the  opposite  side  remains  intact.  In  mydriasis  as  a  sequent  of  oculo- 
motor paralysis,  the  pupil  may  be  made  to  dilate  still  further  by  either 
stimulating  the  sympathetic,  or  by  the  action  of  atropine.  In  man, 
pathological  lesions  of  the  third  nerve  generally  result  in  mydriasis, 
though  the  writer  has  seen  a  case  of  a  contracted  pupil  due  to  neuritis 
of  the  third  on  the  same  side ;  and  M.  Voisin  found  in  one  instance,  in 
the  case  of  a  general  paralytic  who  had  unequal  pupils,  one  of  which  was 
contracted,  that  there  was  an  effusion  of  blood  into  the  nucleus  of  origin 
of  the  third  on  the  same  side.  Besides  its  action  on  the  pupil,  paralysis 
of  the  third  when  complete  causes  paralytic  ptosis,  strabismus  outward 
and  downward,  slight  protrusion,  and  immobility  of  the  eyeball.  There 
is,  of  course,  inability  to  adduct  the  eyeball,  and  consequent  double 
vision.  It  is  well  to  recollect  that  paralysis  may  be  confined  to  individual 
branches  of  the  nerve.  Unilateral  affections  of  the  third  show  them- 
selves in  the  pupil  on  the  same  side  as  the  lesion  in  the  brain.  Intra- 
cranial unilateral  section  of  the  fifth  nerve  causes  on  the  same  side  as 
the  lesion,  fixity  of  the  eyeball,  contraction  and  immobility  of  the  pupil. 
The  want  of  sensibility  soon  leads  to  inflammation  and  ultimate  destruc- 
tion of  the  eyeball.  The  same  pupillary  effect  is  produced  on  section  of 
the  sympathetic,  and  some  suppose  that  the  action  of  the  fifth  on  the 
pupil  is  due  to  the  vasomotor  filaments  which  it  contains. 

The  centre  for  dilatation  of  the  pupil  is  situated  in  the  medulla 
oblongata.  Thence  the  fibres  make  their  exit  partly  through  the 
trigeminus,  partly  through  the  lateral  columns  of  the  cord,  in  the  cilio- 
spinal  region  (from  the  sixth  cervical  to  the  third  dorsal  vertebrae), 
passing  out  by  the  two  lowest  cervical  and  the  first  two  dorsal  nerves 
into  the  cervical  sympathetic.  The  latter  fibres  find  their  way  to  the 
iris,  not  only  through  the  cervical  sympathetic,  but  also  by  the  cavernous 
plexus,  lenticular  ganglion,  and  ciliary  nerves.  It  may  be  interesting 
to  note,  as  having  a  bearing  on  the  question  of  the  power  of  the  vaso- 
motor system  on  the  iris,  that  Landois  and  Stirling  state  that  though  the 
vasomotor  and  oculo-pupillary  fibres  "  lie  in  the  same  trunk  in  the 
neck  they  do  not  issue  from  the  cord  by  the  same  nerve  roots;  the  latter 
come  out  of  the  cord  with  the  anterior  roots  of  the  first  and  second  dor- 
sal nerves  (dog),  while  section  of  the  cord  between  the  second  and  fourth 
dorsal  vertebrae  produces  the  vasomotor  changes  only."1  It  may,  how- 
ever, be  difficult  to  ascertain  whether  the  latter  sections  produce  direct 
pupillary  effects,  as  the  pupil  may  be  influenced  by  the  state  of  the 
bloodvessels.    More  definite  information  on  this  point  is  necessary. 


1  Ferrier  states  that  in  the  monkey  the  second  dorsal  is  the  only  nerve  issuing  from  the  ciliospinal 
axis  which  produces  dilatation  of  the  pupil  on  irritation. 


126     M  A  CE  WEN,  PUPIL  IN  ITS  SE  MEIOLOGICAL  ASPECTS. 

When  the  cervical  sympathetic  is  stimulated,  dilatation  of  the  pupil  en- 
sues ;  and  when  it  is  divided  or  paralyzed,  the  pupil  contracts.  Similar 
results  follow  like  causes  applied  to  the  medulla,  and  especially  to  the 
ciliospinal  zone.  Budge  describes  this  as  the  centre  for  the  dilatation 
of  the  pupil,  and  it  may  be  looked  upon  as  a  secondary  centre.  If  it  be 
admitted  that  there  are  radiating  fibres  in  the  iris,  then  these  are  in- 
nervated by  the  sympathetic,  causing  dilatation  of  the  pupil,  while  the 
oculomotor  innervates  the  circular  fibres.  But  Rouget,  and  many 
others,  do  not  admit  the  existence  of  radiating  fibres,  explaining  the 
action  of  the  cilio-spinal  axis  on  the  pupil  as  being  due  solely  to  its 
vasomotor  control. 

When  the  cervical  sympathetic  is  divided,  the  vessels  of  the  corre- 
sponding side  of  the  head,  face,  ear,  and  mucous  membrane  of  the  mouth, 
become  dilated ;  there  is  sweating  on  that  side  of  the  head,  elevation  of 
temperature,  the  vessels  of  the  iris  are  engorged  with  blood,  and  there  is 
contraction  of  the  pupil.  If  the  peripheral  end  of  the  cut  sympathetic 
be  electrically  stimulated  all  these  phenomena  disappear,  and  the  pupil 
dilates.  Many  infer  from  these  and  other  phenomena,  that  the  action 
of  the  sympathetic  on  the  pupil  is  exercised  through  the  intermediary 
of  the  bloodvessels. 

Unilateral  excitation  of  the  cord  in  the  ciliospinal  region  produces 
dilatation  of  the  pupil  on  the  same  side.  Although  the  ciliospinal  zone 
is  specially  susceptible  to  impressions  giving  rise  to  pupillary  phenomena, 
yet  irritation  applied  to  almost  any  part  of  the  cord  is  apt  to  be  followed 
by  dilatation  of  the  pupil.  This  centre  is  likewise  connected  with  the 
afferent  sensory  nerves,  so  that  painful  impressions  on  the  skin  and 
mucous  membranes  may  reflexly  produce  dilatation  of  the  pupils. 

When  the  corpora  quadrigemina  are  irritated,  both  pupils  contract, 
and  when  destroyed,  dilatation  with  immobility  of  pupils  and  destruction 
of  sight  ensue.  It  will  be  observed,  that  the  pupillary  effect  is  similar 
to  that  produced  by  lesions  of  the  third  nerve. 

Were  Longet's  observation  correct,  one  could  remove  from  an  animal 
the  whole  brain,  with  the  exception  of  the  corpora  quadrigemina,  without 
producing  any  pupillary  indication.  The  writer  would  like  to  have 
further  evidence  on  this  point  before  accepting  this  statement  as  a  fact.1 
Even  were  it  the  case,  it  would,  as  M.  Drouin  points  out,  not  be  correct 
to  conclude  that  lesions  of  the  cortical  masses  have  no  effect  upon  the 
movements  of  the  iris,  as  various  encephalic  modifications  have  distinctive 
pupillary  indications.  It  is  supposed  that  there  are  two  cortical  motor 
centres  for  the  pupil ;  the  one  situated  in  the  base  of  the  first  and  second 
frontal  convolutions,  which,  on  irritation,  causes  dilatation  of  the  pupil 


1  Ferrier  states  that  in  animals  deprived  of  their  cerebral  hemispheres,  a  flash  of  light  befoi-e  their 
eyes  will  cause  the  pupils  to  contract.  Judging  from  this,  the  pupils  must  be  either  medium  or  dilated 
in  such  cases. 


MACE  WEN,  PUPIL  IN   ITS  SE  MEI OLOGIC  AL  ASPECTS.  127 


through  the  ciliospinal  subcentre;  the  other  located  in  the  angular  gyrus, 
connected  with  the  nucleus  of  the  third  nerve  by  means  of  centrifugal 
fibres,  which,  when  irritated,  causes  contraction  of  the  iris  with  conver- 
gent eyes.  These  two  centres  in  the  cortex  of  the  brain,  stated  to  be 
connected  so  precisely,  the  one  with  the  spinal  centre,  the  other  with  the 
oculomotor  beneath  the  aqueduct  of  Sylvius,  are  not  yet  definitely 
established,  and  in  some  measure  are  yet  inferential. 

In  considering  the  manner  in  which  cerebral  lesions  may  act  upon  the 
pupils,  it  is  necessary  to  weigh  the  possible  participation  of  the  various 
nerve  centres,  and  the  effects  of  modifications  of  the  brain  as  a  whole 
upon  them,  and  also  the  relation  of  the  state  of  the  cerebral  circulation 
to  that  of  the  iris. 

The  phenomena  produced  by  lesions  of  the  cerebellum  upon  the  pupil 
are  varied,  generally  myosis,  occasionally  mydriasis ;  both  being  accom- 
panied by  strabismus. 

Meningeal  affections  may  extend  so  widely  that  many  parts  of  the 
brain  and  basal  nerves  may  be  implicated  ;  and  probably  by  reflex  sym- 
pathetic action,  changes  may  be  induced  in  the  eye  and  iris.  When  one 
remembers  that  the  internal  carotid  supplies  both  the  pia  mater  and  globe 
of  the  eye,  and  that  the  same  vasomotor  centre  supplies  the  vascular 
nerves  of  those  arterial  branches,  the  influence  of  the  meningeal  affec- 
tions over  the  iris  may  be  understood. 

There  is  considerable  divergence  of  opinion  regarding  the  manner  in 
which  certain  pupillary  movements  are  brought  about,  and  also  as  to  the 
exact  mechanism  controlling  these  movements.  While  all  admit  the 
existence  of  the  sphincter  of  the  iris,  there  is  no  unanimity  as  to  the 
mode  by  which  dilatation  is  effected.  While  some  believe  that  there  are 
muscular  radiating  fibres  whose  function  it  is  to  dilate  the  iris,  others 
deny  their  existence,  believing  that  the  dilatation  and  contraction  of 
accommodation  take  place  in  virtue  of  the  inherent  elasticity  of  the  iris. 
Those  holding  the  latter  view  say,  physiology  shows  that  the  movements 
of  the  iris  are  controlled  in  two  ways,  the  one  being  functional  or  active, 
relating  to  accommodation  during  the  exercise  of  vision,  the  other  being 
passive,  depending  on  the  variations  of  the  circulation  in  the  encephalon 
and  iris.  The  former  movements  are  those  arising  from  the  impres- 
sions of  light  on  the  retina  communicated  through  the  second  nerve  to 
the  corpora  quadrigemina,  which  produce  contraction  of  the  pupil 
through  the  oculomotor  acting  on  the  iris.  In  those  functional  move- 
ments the  changes  in  the  pupil  are  brought  about  by  the  elasticity  of  the 
iris.  The  passive  or  vascular  alterations  of  calibre  are  quite  of  a  different 
character,  and  are  independent  of  visual  impressions,  though  the  power 
of  accommodation  may  remain.  In  those  the  movements  of  the  pupil 
are  regulated  by  the  vascular  system  of  the  iris,  which  is  in  complete 
harmony  with  that  of  the  encephalon.    Myosis  ensues  when  the  vessels 


128     MACE  WEN,  PUPIL  IN  ITS   SEMEIO  LOGICAL  ASPECTS. 

of  the  encephalon  and  those  of  the  iris  are  dilated  ;  and  dilatation  of  the 
pupil  corresponds  to  ansemia  of  the  encephalon  and  iris.  It  is  in  this 
way  that  congestion  of  the  brain  and  its  membranes,  the  result  of  paral- 
ysis of  the  cervical  sympathetic,  produces  fluxion  or  paralytic  dilatation 
of  the  vessels  of  the  iris  and  contraction  of  the  pupil ;  while  in  irrita- 
tion of  the  sympathetic,  in  ischsemia  of  the  brain,  due  to  epilepsy,  syn- 
cope, strong  moral  emotions,  powerful  irritation  of  the  sensory  nerves, 
etc.,  the  vessels  of  the  iris  being  contracted,  mydriasis  ensues.  Regard- 
ing the  action  the  various  states  of  the  encephalon  might  have  on  the 
pupiis,  it  is  said  that  one  has  only  to  determine  what  effect  the  lesions 
have  on  the  circulation.  Prominent  among  those  who  have  advocated 
this  view  is  Mosso,  of  Turin,  who  declares  that  the  size  of  the  pupil 
follows  exactly  the  oscillations  of  the  bloodvessels,  and  M.  Drouin  warmly 
espouses  the  same  view,  regarding  the  pupil  as  the  manometer  of  the 
cerebral  circulation.  M.  Francois  Frank  refutes  this  theory,  and  states 
that  the  movements  of  the  pupil  are  quite  independent  of  the  condition 
of  the  bloodvessels;  the  evidence  he  advances  in  support  is  far  from 
conclusive. 

There  is  this  difference  between  the  influence  exerted  on  the  pupil 
by  cerebral  affections  and  those  arising  from  the  ciliospinal  axis,  the 
former  can  affect  the  size  of  the  pupil  in  two  ways :  first,  through  the 
medium  of  the  bloodvessels,  second,  by  injuring  the  apparatus  controlling 
the  functional  movements  of  the  iris  (the  optic  and  oculomotor  nerves 
and  corpora  quadrigernina)  ;  while  the  latter,  the  ciliospinal,  can  affect 
the  pupils  in  only  one  way,  by  means  of  the  reflex  phenomena  deter- 
mining dilatation  and  contraction  of  the  vessels. 

Method  of  Examining  the  Pupil. — In  examining  the  pupil,  the 
shape,  size,  activity,  and  any  difference  existing  between  the  two  pupils, 
should  be  noted.  The  following  rules  ought  to  be  attended  to.  The 
patient  ought  to  face  some  source  of  light,  such  as  a  window. 

1.  Both  eyelids  ought  to  be  closed,  and  after  the  lapse  of  a  few  seconds 
both  ought  to  be  simultaneously  opened,  when  the  observer  should  note 
w7hether  they  contract  equally. 

2.  One  eyelid  should  then  be  closed  for  half  a  minute ;  observe  on 
opening  it  whether  there  be  immediate  contraction  in  that  pupil,  and 
whether  simultaneous  contraction  takes  place  in  the  opposite  pupil.  The 
same  should  be  repeated  in  the  opposite  eye.  By  this  means  an  amau- 
rotic eye  would  be  detected,  as  in  it  the  consensual  movement  persists, 
while  the  direct  movements  are  abolished. 

Pupilometers.  Many  pupilometers  have  been  invented,  such  as  those 
of  Olbers,  Follin,  Fick,  Badel,  Galezowski,  Landolt,  Gorham,  etc., 
some  of  them  being  ingenious  instruments.  For  practical  purposes, 
however,  Hutchinson's  idea  of  the  disk  of  polished  steel,  with  holes 
punched  in  it,  or  the  simple  narrow  white  card,  having  marked  on  it  a 


MAC  EWE  1ST,  PUPIL  IN   ITS  SE  MEI  OLOGIC  A  L  ASPECTS.  129 


series  of  black  dots,  measuring  from  one  to  nine  millimetres,  is  sufficient. 
When  in  use  it  is  placed  close  to  the  eye,  and  the  dot  which  corresponds 
most  to  the  size  of  the  pupil  is  noted,  and  its  exact  size  in  millimetres  is 
read  off.  This  has  been  employed  by  M.  Drouin,  and  Dr.  Finlayson 
figures  it  in  his  work  on  clinical  medicine.  The  widest  dilatation  of  the 
iris  never  exceeds  nine  millimetres. 

Personal  Observations  on  the  Pupils. — The  data  upon  which 
the  following  remarks  are  founded  are  based  upon  personal  experience. 
The  various  facts  were  gleaned  and  recorded  as  isolated  phenomena. 
It  was  only  in  reviewing  and  collating  these,  the  conception  evolved, 
that,  besides  the  effect  on  the  pupil  of  lesions  of  certain  brain  and  spinal 
centres  aud  their  nerves,  there  were  general  cerebral  conditions,  which 
were  accompanied  by  definite  pupillary  phenomena,  with  sufficient  con- 
stancy to  enable  conclusions  to  be  formulated  regarding  them.  When 
these  pupillary  states  are  fenced  with  proper  reservations,  they  form 
valuable  aids  to  the  diagnosis  of  some  of  the  general  conditions  of  the 
brain. 

When  the  function  of  the  brain  is  temporarily  suspended,  the  pupils 
are  in  a  state  of  stabile  mydriasis.  It  matters  not  what  the  cause  of  this 
suspension  of  function  may  be,  the  pupillary  phenomena  are  identical  as 
long  as  this  condition  lasts. 

In  peripheral  injuries,  involving  large  extents  of  surface,  such  as  the 
mangling  of  both  thighs  by  a  railway  accident,  a  state  of  shock  is  fre- 
quently induced,  in  which,  along  with  complete  insensibility  and  the 
usual  accompanying  phenomena,  the  pupils  are  widely  dilated  and  fixed. 
Reaction  in  such  cases  is  often  heralded  by  an  alteration  in  the  pupil- 
lary state,  the  mydriasis  giving  way  somewhat,  the  pupil  at  the  same 
time  becoming  mobile,  and  soon  after,  vomiting  or  other  sign  of  reaction 
sets  in.  The  same  phenomena  are  seen  when  shock  is  induced  by  blows 
upon  the  epigastrium,  by  severe  pain,  such  as  may  be  occasioned  by 
injury  of  the  testicle,  and  by  powerful  mental  impressions.  Again, 
when,  instead  of  the  injury  being  peripheral,  it  is  applied  to  the  brain 
itself,  and  is  of  sufficient  severity  to  cause  suspension  of  the  cerebral 
function,  the  pupils  are  widely  dilated  and  fixed. 

As  to  this  state  of  central  shock  or  cerebral  concussion,  writers  are  at 
variance  with  one  another  concerning  the  pupillary  condition  attending 
it.  Some  state  that  the  pupils  are  dilated,  others  that  they  are  con- 
tracted, most  that  they  are  variable,  while  a  few  state  that  they  are 
unequal.  Hospital  surgeons,  who  make  a  daily  or  a  less  frequent  visit 
to  their  wards,  have  few  opportunities  of  seeing  uncomplicated  cases  of 
concussion  of  the  brain,  as  in  the  majority  of  instances  the  phenomena 
attending  this  condition  pass  off  within  a  period  of  hours,  and  in  many 
before  the  patient  reaches  the  hospital.  As  an  "interne"  in  the  Royal 
Infirmary,  the  writer  witnessed  a  number  of  such  cases,  the  symptoms 

NO.  CLXXXVII. — JULY,  1887.  9 


130     MACEWEN,  PUPIL   IN   ITS  SEMEIOLO  GIC  AL  ASPECTS. 


in  each  of  these  passing  off  in  a  few  hours ;  and  afterward,  while  occu- 
pying the  post  of  Casualty  Surgeon  in  Glasgow,  the  writer  had  the  for- 
tune of  seeing,  and  the  opportunity  of  observing  to  a  conclusion,  at  least 
twenty  well-marked  instances.  The  data  thus  derived  pointed  clearly 
to  the  conclusion  that  in  uncomplicated  cases  of  concussion  the  pupils 
are  widely  dilated  and  fixed.  One  of  the  earliest  indications  of  recovery 
from  this  state  is  to  be  found  in  the  pupils,  the  wide  dilatation  relaxing 
somewhat,  accompanied  by  a  slight  mobility.  During  the  period  of 
rallying  the  pupil  is  very  variable,  and  generally  more  or  less  con- 
tracted. In  cases  of  concussion,  which  are  complicated  by  brain  lesion, 
such  as  slight  compression,  the  pupillary  phenomena,  the  result  of  con- 
cussion, remain  until  the  latter  state  passes  off,  when  the  slight  com- 
pression manifests  itself,  among  other  ways,  by  a  pupillary  state,  such 
as  inequality,  contraction,  etc.  In  this  way,  concussion  may  temporarily 
mask  other  and  more  serious,  though  more  limited  brain  lesions,  which 
may  manifest  themselves  when  it  has  subsided.  If  these  two  conditions 
are  not  discriminated,  the  pupillary  phenomena  of  the  one  may  be 
attributed  to  that  of  the  other. 

In  hemorrhage  considerable  loss  of  blood  may  be  borne  without 
inducing  marked  pupillary  changes,  as  long  as  the  blood  be  not  removed 
from  the  body  so  rapidly  as  to  induce  syncope.  When,  however,  the 
amouut  of  blood  lost  is  great,  equalling  one-seventh  of  the  whole,  the 
cerebral  irritability  is  increased,  and  is  accompanied  by  myosis.  When 
the  depletion  is  carried  much  further,  so  that  the  amount  lost  is  equal 
to  one-fifth  of  the  whole,  the  cerebral  ansemia  is  so  great  as  seriously  to 
reduce  the  functional  power  of  the  brain ;  then  the  pupils  are  dilated, 
and  if  this  depletion  be  pushed  so  as  to  induce  syncope,  they  become 
widely  dilated  and  fixed.  When  they  are  in  this  condition,  it  is  inte- 
resting to  note  how  quickly  they  undergo  change  when  the  cerebral 
anaemia  is  dispelled  by  lowering  the  head  and  raising  the  limbs,  so  as  to 
empty  the  latter  of  their  vascular  contents,  and  thereby  replenishing  the 
heart  and  brain.  The  pupils  then  become  mobile,  less  dilated,  and  may 
fall  to  medium  size,  or  even  become  contracted,  according  to  the  amount 
of  blood  thrown  into  the  cranium.  This  is  quite  in  accordance  with  the 
observation  of  B.  Sequard,  who  has  shown  that  when  an  animal  is  sus- 
pended by  the  hind  legs,  contraction  of  the  pupil  occurs,  comparable  to 
that  obtained  by  ablation  of  the  superior  cervical  ganglia. 

Much  the  same  pupillary  phenomena  are  seen  during  the  action  of 
drugs  which  affect  the  cerebro-spinal  system,  even  in  those  which,  in  the 
first  instance,  produce  myosis.  In  such,  if  the  action  of  the  drug  be 
pushed,  a  stage  is  a:  rived  at,  when  the  function  of  the  respiratory  and 
cardiac  centres  is  so  seriously  compromised  that  the  pupils  become 
widely  dilated  and  fixed.  This  may  be  illustrated  by  the  action  of  three 
drugs,  opium,  chloroform,  and  alcohol.    When  the  physiological  effect 


M  ACE  WEN,  PUPIL  IN  ITS   SE  MEIO  LOGIC  AL   ASPECTS.  181 


of  a  large  dose  of  opium  is  fully  established,  the  pupils  are  in  a  state  of 
stabile  myosis,  and  continue  so  as  long  as  the  cardiac  and  respiratory 
centres  are  active.  When  the  dose  is  sufficiently  large  this  stabile 
myosis  is  succeeded  by  a  rapid  change  to  that  of  stabile  mydriasis,  indi- 
cating that  the  function  of  the  cerebrum  and  the  medulla  has  been  so 
dangerously  interfered  with,  that  it  falls  practically  into  abeyance, 
the  cardiac  action  continuing  for  a  brief  jDeriod,  partly  through  the 
inherent  ganglionic  cardiac  centres,  the  respiration  meanwhile  being 
extremely  slow,  irregular,  and  gasping.  If  energetic  measures  are  not 
promptly  adopted,  the  life  of  the  patient  is  measured  by  minutes.  This 
has  been  verified  by  frequent  instances.  Though  a  most  dangerous 
symptom,  it  is  not  absolutely  hopeless,  as  is  illustrated  by  a  case  of  this 
kind  which  fell  under  the  writer's  observation,  in  which  the  patient  was 
restored  by  means  of  artificial  respiration  continued  for  two  consecutive 
hours  (the  stomach  having  previously  been  duly  washed  out).  At  the 
termination  of  an  hour  and  a  half,  when  a  pause  Avas  made  in  the  arti- 
ficial respiration,  in  order  to  test  the  condition  of  that  function,  there 
was  only  one  gasp,  as  if  the  air  had  just  distended  the  lungs  after  their 
artificial  compression.  The  pulse,  at  the  same  time,  was  a  mere  thread, 
difficult  to  perceive.  At  the  end  of  another  quarter  of  an  hour,  feeble, 
shallow  respiratory  efforts  were  made  by  the  patient.  The  artificial 
breathing  was  carried  on  for  a  further  period  of  fifteen  minutes,  during 
which  the  lividity  of  the  face  and  surface  of  the  skin  cleared  away,  and 
after  that  the  patient  was  able  to  breathe  without  further  aid.  Patient 
ultimately  recovered,  and  was  alive  four  years  afterward.  It  was  inte- 
resting to  note  that  after  she  had  recovered  partial  sensibility,  and  when 
she  was  able  to  breathe  of  her  own  accord,  the  pupils  returned  to  the 
condition  of  myosis  from  that  of  mydriasis,  in  which  they  had  been 
during  the  time  that  artificial  respiration  had  to  be  continued ;  or,  in 
other  words,  they  remained  dilated  until  the  function  of  the  brain  had 
partially  recovered. 

This  condition  of  stabile  mydriasis  setting  in  so  rapidly,  and  taking 
the  place  of  the  myosis,  shows  that  the  opium  has  no  longer  the  power 
of  asserting  its  well-known  influence  on  the  pupil  in  the  presence  of  the 
suspension  of  the  brain  function.  The  change  indicates  that  death  is 
imminent.  The  mechanism  producing  contraction  of  the  pupil  in  these 
instances  may  probably  be  the  congestion  of  the  brain  and  its  mem- 
branes, as  well  as  the  ocular  vessels ;  and  the  rapid  dilatation  of  the 
pupil  to  the  anaemia  coincident  with  the  suspension  of  function. 

It  is  probable  that  statements  made  in  some  text-books,  regarding  the 
action  of  opium,  as  occasionally  causing  dilatation  of  the  pupils  may  be 
explained  in  this  way.  When  death  ensues  after  opium-poisoning,  the 
pupils  first  relax  somewhat,  and  then  become  medium.  From  this  it 
will  be  seen,  it  is  quite  erroneous  to  suppose  that  the  pupils  will  neces- 


132     MACE  WEN,  PUPIL   IN  ITS   SEM  BIOLOGICAL  ASPECTS. 

sarily  be  found  contracted  in  the  cadaver  after  death  from  opium- 
poisoning.  In  six  instances  which  have  come  under  personal  observa- 
tion, the  pupils  were  found  to  measure  from  four  to  six  millimetres  after 
death,  although  they  measured  about  two  millimetres  shortly  before 
death.  It  is  right  to  remember  that  the  apparent  congestion  of  the 
internal  organs  in  opium-poisoning  may,  in  part,  be  due  to  the  great 
fluidity  and  dark  color  of  the  blood. 

The  coma  arising  from  alcohol,  as  was  pointed  out  by  me  in  1879,  may 
be  distinguished  from  that  due  to  other  causes  by  the  fact  that  when  the 
patient  is  left  lying  undisturbed  for  twenty  minutes,  the  pupils  are  in  a 
state  of  myosis,  pin-head  contraction.  If  an  attempt  be  then  made  to 
arouse  the  patient  by  shaking  him,  or  pulling  his  hair,  though  he  still 
remain  quite  comatose,  his  pupils  will  slowly  dilate,  until,  if  the  physical 
irritation  be  continued,  they  become  fully  dilated.  If  the  patient  be 
then  left  undisturbed,  the  pupils  remain  dilated  for  a  period  of  variable 
duration — minutes,  as  a  rule,  after  which  they  begin  to  contract,  doing 
so  at  a  very  slow  rate  until  they  reach  their  former  dimensions.  The 
time  taken  for  the  transition  from  the  fully  dilated  stage  to  that  of  pin- 
head  contraction,  is  from  five  to  ten  minutes,  varying  according  to  the 
intensity  of  the  coma.  In  some  rare  cases,  where  the  coma  is  very 
intense,  the  change  is  completed  in  less  than  five  minutes.  In  instances 
in  which  the  patient  is  not  deeply  comatose,  the  dilatation  continues  for 
ten  minutes,  and  then  contraction  sets  in  at  a  very  sluggish  rate.  In 
persons  in  whom  the  alcoholic  coma  is  passing  off,  and  who  are  merely 
insensible,  and  who  can  be  temporarily  roused,  the  dilatation  of  the  pupil 
once  established  continues,  or  it  may  become  smaller,  though  it  does  not 
again  attain  the  same  degree  of  contraction  it  formerly  did.  These 
observations  have  been  subsequently  verified  in  many  hundreds  of  cases. 
In  some  uncommon  instances  of  cerebral  compression,  through  apoplexy 
or  other  cause,  the  contracted  pupil  will  be  slightly  enlarged  on  stimula- 
tion (not  full  dilatation,  as  in  alcohol),  and  very  soon,  in  most,  immedi- 
ately thereafter,  it  will  contract  to  its  former  size. 

But  when  the  dose  of  alcohol  is  poisonous,  and  the  patient  is  about  to 
succumb  from  its  effects,  the  pupils,  after  being  contracted  as  above,  pass 
rapidly  into  complete  stabile  mydriasis.  This  is  a  condition  which  must 
be  very  seldom  seen  as  arising  from  alcohol,  but  was  once  observed  by 
the  writer,  in  the  case  of  a  man  who  had  half  an  hour  previously  drank 
off  at  a  draught  a  quart  of  strong  alcohol  (proof  strength)  ;  the  pupils 
becoming  widely  dilated  and  fixed,  the  patient  dying  fifty  minutes  after- 
ward. Here  the  function  of  the  medulla  had  become  interrupted,  and 
finally  suspended,  just  as  in  opium-poisoning. 

In  chloroform  narcosis,  the  same  pupillary  phenomena  are  observed 
during  the  extreme  stages.  From  personal  observations,  extending  over 
several  hundred  carefully  recorded  cases,  it  is  seen  that  the  pupils  are  in 


M  AC  E  WEN,  PUPIL   1 1ST   ITS   SEMEIOLOGICAL  ASPECTS.  133 


a  very  variable  state  during  the  preliminary  periods,  much  too  variable 
to  permit  any  rule  being  formulated  regarding  them.  When,  however, 
reflex  action  is  abolished,  except  in  the  cardiac  and  respiratory  centres, 
the  pupils  become  contracted  and  fixed.  This  may  be  regarded  as  the 
safety  zone  of  complete  chloroform  narcosis.  But  if  the  anaesthesia  be 
pushed  beyond  this  stage  wide  dilatation  of  the  pupils  ensues,  indicating 
a  suspension  of  function  in  the  cardiac  and  respiratory  centres.  This  is 
a  most  critical  condition,  though  one  by  no  means  necessarily  fatal,  as 
by  lowering  the  head  and  raising  the  floor  of  the  table,  and  by  promptly 
carrying  out  artificial  respiration,  even  while  feeble  respiratory  efforts 
are  being  made  by  the  patient,  the  danger  may  be,  and  very  frequently 
has  been  averted.  Given  a  person  free  from  organic  lesion  of  the  nerve 
centres,  heart,  or  lungs,  in  whom  during  chloroform  narcosis,  stabile 
mydriasis  suddenly  occurs  as  a  result  of  the  action  of  chloroform  on  the 
respiratory  centres,  the  patient  ought  to  recover,  if  artificial  respiration 
coupled  with  the  lowering  of  the  head,  be  promptly  resorted  to,  and  the 
former  efficiently  carried  out  It  is  interesting  to  note  in  such  cases  the 
marked  effect  produced  by  elevating  the  foot  of  the  table,  so  as  suddenly 
to  place  the  patient's  head  and  thorax  at  a  very  low  level,  the  pupils 
becoming  quickly  contracted.  In  this  connection,  however,  it  ought  to 
be  borne  in  mind,  that  one  of  the  earliest  indications  of  a  return  of 
reflex  action  is  vomiting,  which,  as  a  rule,  is  accompanied  by  dilated 
pupils,  the  result  of  cerebral  anaemia. 

In  cases  where  the  functions  of  the  cerebrospinal  system,  especially  of 
the  cardiac  and  respiratory  centres,  have  already  been  enfeebled  (by 
organic  lesion  or  otherwise),  chloroform  acts  more  powerfully  ;  a  few 
whiffs  sufficing  to  induce  complete  insensibility,  and  the  administration 
of  an  ordinary  dose  giving  rise  to  an  alarming  state,  which  only  prompt 
measures  can  prevent  from  becoming  fatal.  In  such  cases  the  pupils 
very  readily  pass  into  wide  dilatation  with  a  very  small  amount  of  chlo- 
roform. 

When  the  function  of  the  brain  is  suspended  by  want  of  oxygenated 
blood,  the  pupils  are  widely  dilated  and  fixed.  This  may  be  seen  in 
cases  of  asphyxia  either  by  poisonous  gases  or  arising  from  mechanical 
causes.  It  was  once  observed  by  the  writer  in  two  men  who  had  all  but 
succumbed  by  inhaling  coal-gas,  emanating  from  a  broken  gaspipe  in 
their  bedroom ;  and  it  is  also  seen  in  cases  of  hanging. 

Turning  to  the  effects  of  pressure  exercised  upon  the  brain  as  a  whole, 
it  produces  pupillary  states  varying  according  to  its  amount.  AVhen  it 
is  sufficient  to  place  in  abeyance  the  cerebral  function,  mydriasis  occurs  ; 
and  when  of  much  less  degree,  causing  only  a  small  area  to  be  involved, 
it  is  usually  followed  by  myosis.  The  following  is  a  typical  case,  illus- 
trating these  points  as  well  as  the  most  carefully  planned  ami  skilfully 
executed  experiment  could  do. 


134     M  ACE  WEN,  PUPIL   IN   ITS   SEMEIOLOGIC  AL  ASPECTS. 


While  acting  as  House  Surgeon  in  the  Royal  Infirmary,  Glasgow,  in 
1870,  the  writer  had  the  opportunity  of  observing  the  following  case: 

A  well-developed  and  strongly  built  man,  about  twenty-eight  years  of 
age,  was  brought  into  the  Infirmary  in  an  unconscious  state,  having  fallen 
from  a  height  about  an  hour  previously.  There  were  bruises  on  his  face, 
nose,  and  forehead,  and  there  was  slight  oozing  of  blood  from  both 
nostrils.  He  was  deeply  comatose,  his  breathing  was  stertorous,  his 
pulse  slow  and  feeble,  and  the  pupils  of  both  eyes  were  widely  dilated 
and  fixed.  Urine  and  feces  had  been  passed  involuntarily.  This  state 
continued  for  fully  half  an  hour  after  admission,  during  which  his 
pulse  became  so  feeble,  as  sometimes  to  be  scarcely  perceptible ;  his 
breathing  was  even  more  deeply  stertorous,  and  it  was  accompanied  by 
lividity  of  the  face.  At  the  expiration  of  this  period,  a  sudden  gush  of 
blood  from  both  nostrils  poured  forth  as  a  torrent,  causing  wide  disten- 
tion of  the  nasal  alse.  This  continued  for  full  two  minutes,  then  quickly 
lessened  in  quantity,  becoming  a  mere  trickling,  which  lasted  half  an 
hour.  The  pupils,  which  had  been  widely  dilated  and  fixed  from  the 
time  of  his  admission  into  the  hospital  up  to  the  very  moment  when  the 
blood  began  to  escape  in  such  volumes  from  both  nostrils,  were  found  at 
the  expiration  of  two  minutes,  during  which  it  flowed,  to  have  become 
medium,  to  be  quite  active,  readily  contracting  when  exposed  to  light, 
and  quickly  dilating  when  shaded.  Along  with  this,  the  lividity  of  the 
face  disappeared,  the  breathing  became  free,  though  the  pulse  was 
extremely  weak,  and  the  patient  pale.  He  however  soon  recovered  con- 
sciousness, answered  a  number  of  questions  correctly,  and  expressed 
surprise  at  finding  himself  in  the  infirmary.  He  also  remembered,  and 
was  able  to  describe  some  of  the  circumstances  connected  with  the  acci- 
dent which  caused  his  injuries.  This  stage  lasted  two  hours,  the  pulse 
and  color  of  the  face  steadily  improved,  and  during  the  whole  time  the 
pupils  were  active  and  normal.  Half  an  hour  later,  the  pupils  began 
to  be  sluggish  and  contracted.  Three  hours  after  the  hemorrhage  they 
were  very  sluggish  and  contracted.  Four  hours  later,  they  did  not 
respond  to  light,  though  they  were  not  so  contracted  as  they  had  been 
half  an  hour  previously.  Patient  no  longer  answered  questions,  but  still 
was  sensible  to  external  impressions,  especially  of  a  painful  kind.  Six 
hours  after  the  hemorrhage  the  patient  was  deeply  comatose,  and  otherwise 
much  in  the  same  condition  as  when  admitted,  his  pupils  having  again 
become  widely  dilated  and  fixed.  Ten  hours  subsequently  to  the  hemor- 
rhage (ten  and  a  half  hours  from  admission)  breathing  became  very 
labored,  the  lividity  of  the  face  marked,  pulse  flickering,  and  death 
ensued  about  twelve  hours  and  twenty  minutes  after  the  hemorrhage 
from  the  nose. 

The  post-mortem  examination  showed  that  the  cribriform  plate  of  the 
ethmoid  was  extensively  fractured,  the  aperture  between  the  fractured 
bones  being  filled  with  clot ;  the  crista  gallae  was  driven  upward,  the 
anterior  part  of  the  longitudinal  sinus  was  ruptured,  and  a  clot  of  blood 
existed  between  the  dura  mater  and  the  skull,  filling  the  greater  part  of 
the  anterior  fossse,  and  pushing  backward  the  brain.  Both  frontal  lobes 
were  much  compressed,  the  convolutions  were  flattened,  and  the  brain 
tissue  comprising  them  was  somewhat  softened.  The  brain,  as  a  whole, 
bore  evidence  of  compression,  but  it  was  otherwise  healthy.  With  the 
exception  of  a  fracture  of  both  bones  of  the  leg,  there  were  no  other 
injuries. 


M  A  CE  WEN,  PUPIL   IN   ITS   SEMEIO  LOGICAL  ASPECTS. 


135 


Remarks. — This  case  may  be  divided  into  four  periods,  each  being 
accompanied  by  a  peculiar  pupillary  condition.  First,  there  was  a 
period  of  severe  intracranial  pressure,  indicated  by  symptoms  of  cerebral 
compression,  in  which  the  brain  function  was  for  the  most  part  sus- 
pended. The  pupils  at  this  stage  were  widely  dilated  and  fixed.  This 
condition  was  present  at  the  time  of  patient's  admission,  and  half  an 
hour  afterward  ended  abruptly  on  the  escape  of  blood  from  the  interior  of 
the  skull.  Second,  with  the  relief  of  the  intracranial  pressure,  the  indica- 
tions of  compression  of  the  brain  disappeared,  its  functions  returned,  the 
patient  regaining  consciousness.  The  pupils  then  became  normal,  re- 
sponding actively  to  the  alternate  action  of  light  and  shade.  This  state 
wras  the  immediate  sequence  of  the  relief  of  the  pressure  on  the  brain  by 
the  escape  of  the  pent-up  blood,  and  it  continued  for  two  hours,  until 
after  the  period  of  reaction  had  set  in.  Third,  there  was  a  period  of 
slight  cerebral  pressure,  due  to  the  recurrence  of  hemorrhage  within  the 
skull,  occurring  shortly  after  reaction  had  set  in.  This  was  the  direct 
result  of  the  reaccumulation  of  blood  within  the  skull,  and  the  conse- 
quent pressure  on  the  brain,  a  clot  having  filled  the  aperture  in  the 
fractured  ethmoid.  The  patient  in  this  stage  had  become  drowsy.  The 
pupils  gradually  lost  their  activity,  becoming  very  sluggish  and  some- 
what later  contracted.  This  period  lasted  about  four  or  five  hours.  It 
corresponded  to  slight  cerebral  pressure.  Fourth,  a  stage  of  severe 
intracranial  pressure  ensued,  marked  by  all  the  symptoms  of  cerebral 
compression  and  accompanied  by  widely  dilated  and  fixed  pupils.  This 
lasted  about  four  and  a  half  hours,  ending  in  death.  This  corresponded 
to  the  first  stage  on  admission,  the  function  of  the  brain  having  again 
become  suspended.    In  a  tabulated  form  it  would  appear  thus  : 

Pressure.  Action  on  Brain.  Effect  on  Pupil. 

1.  Very  severe.  Function  almost  in  abeyance.       Stabile  mydria- 

sis. 

2.  Removal  of  pressure.     Restoration  of  function.  Normal  and  ac- 

tive. 

3.  Slight.  Interruption  of  function.  Contracted  and 

sluggish. 

4.  Very  severe.  Suspension  of  function,  ending     Stabile  mydria- 

in  its  abolition.  sis. 

The  same  pupillary  phenomena  arising  from  pressure,  induced  by  a 
pathological  cause,  are  illustrated  by  a  case  of  tubercular  meningitis 
with  its  accompanying  effusion,  which  is  given  elsewhere  in  detail.  On 
admission,  the  patient,  who  was  insensible,  gave  vent  to  the  peculiar 
"  hydrocephalic  cry."  She  could  move  her  limbs  freely,  her  pupils  were 
in  a  state  of  myosis  (stabile).  At  this  stage,  it  was  probable  thai  she 
suffered  from  interference  with  cerebral  function,  caused  by  effusion  of 
fluid  exercising  a  degree  of  pressure  on  the  brain.    A  few  days  subse- 


136     MACEWEtf,  PUPIL  IN  ITS   SEMEIOLOGIC  AL  ASPECTS. 


quently,  she  became  unconscious,  pulse  very  feeble,  respiration  labored 
and  shallow  accompanied  by  great  lividity  of  the  face,  and  a  markedly 
subnormal  temperature.  The  pupils  were  then  in  a  state  of  stabile 
mydriasis.  It  was  diagnosticated  that  the  fluid  had  further  increased, 
and  was  now  exercising  very  severe  pressure  on  the  brain,  placing  its 
function  in  abeyance,  with  the  exception,  perhaps,  of  the  respiratory 
and  cardiac  centres,  which,  though  seriously  interfered  with,  were  still 
able  to  act  to  a  slight  extent.  To  relieve  this  pressure,  a  puncture  was 
made  through  the  brain  membranes,  when  a  large  quantity  of  cerebro- 
spinal fluid  escaped  in  a  jet.  While  the  fluid  flowed  away,  the  respira- 
tions improved,  the  cardiac  impulse  increased  in  strength,  the  lividity 
disappeared,  the  pupils  became  much  smaller,  and  shortly  afterward  be- 
came normal  in  size  and  sensitive  to  light,  though  they  were  somewhat 
sluggish.  This  condition  continued  for  twenty-four  hours,  the  tempera- 
ture increasing  from  subnormal  to  102.8°  F.  Ultimately  the  patient 
died. 

The  condition  may  be  thus  formulated : 


Pressure. 

1.  Slight. 

2.  Severe. 

3.  Eemoval  of  pressure. 


Action  on  Brain. 
Interference  with  function. 
Function  in  abeyance. 


Effect  on  Pupil. 
Myosis. 

Stabile  mydria- 
sis. 

Mobile  and  al- 
most normal. 


Function  nearly  quite  restored. 


Twelve  cases  of  obliteration  of  function  from  pressure  and  bruising  of 
the  brain.  Numerous  instances  of  severe  injury  to  the  cranial  contents 
have  been  observed  by  the  priter  in  which  both  pupils  were  widely 
dilated  and  fixed ;  post-mortem  examination  afterward  showing  exten- 
sive destruction  of  the  cerebral  substance.  In  twelve  such  cases  the 
patients  died  within  a  few  hours  after  the  accident.  The  post-mortem 
in  these  showed,  besides  serious  injury  of  the  skull,  that  both  cerebral 
hemispheres  had  been  encroached  upon  by  extensive  extravasations  of* 
blood,  or  by  portions  of  bone  or  foreign  matter  driven  into  the  cerebral 
substance,  exercising  severe  and  general  pressure  and  producing  exten- 
sive laceration  of  the  brain.  In  all  of  them  there  was  destruction  of 
both  hemispheres,  sufficient  to  obliterate  function. 

Four  cases  of  extensive  bruising  and  laceration  of  the  brain  without 
pressure.  Besides  these,  there  were  four  cases  in  which  a  sufficient 
hiatus  had  been  formed  in  the  osseous  walls  of  the  skull  to  prevent  the 
possibility  of  pressure  being  exercised  on  the  hemispheres,  and  yet  the 
pupils  were  dilated;  the  extensive  laceration  and  severe  bruising  of  the 
brain  having  destroyed  the  function  of  the  part.  Nor  is  the  widely 
dilated  and  fixed  pupils  arising  from  cerebral  pressure  limited  to  surface 
lesions,  or  such  as  are  caused  by  traumatism.    In  cases  of  extensive 


MACEWEN,  PUPIL  IX   ITS   SE  M  EIOL  OGIC  AL  ASPECTS.  137 

hemorrhage  from  the  basal  or  deep  cerebral  arteries,  causing  great  pres- 
sure or  laceration  of  the  brain,  widely  dilated  and  fixed  pupils  are  seen, 
and  they  are  accompanied  by  abolition  of  cerebral  function.  In  one 
instance  of  this  kind  which  came  under  personal  observation,  the  lateral 
ventricles  had  become  greatly  distended  with  blood,  the  coma  was  pro- 
found, and  both  pupils  were  in  a  state  of  stabile  mydriasis,  this  being  the 
usual  condition  of  the  pupils  in  such  lesions.  In  another  instance,  a 
large  cerebral  abscess  had  burst  into  the  ventricles  and  this  was  notified 
by  the  sudden  accession  of  deep  coma,  accompanied  by  widely  dilated 
and  fixed  pupils.  These  phenomena  are  in  accordance  with  those  ob- 
served by  others,  who  have  pointed  out  that  congestion  of  the  mem- 
branes and  slight  hemorrhage  into  the  ventricles  is  accompanied  by 
contraction  of  the  pupils,  while  profuse  hemorrhage  into  the  ventricles 
produces  dilatation  of  the  pupils.  In  the  latter  case,  it  is  supposed  that 
the  result  ensues  from  compression  of  the  common  motors,  but  the  pres- 
sure no  doubt  causes  suspension  of  function  of  the  brain  as  a  whole.1 

It  is  true  that  cerebellar  hemorrhage  is  generally  indicated  by  con- 
tracted pupils,  but  this  is  not  always  so.  When  the  pupils  are  con- 
tracted the  extravasation  is  slight,  but  when  the  outpouring  of  blood  is 
much  greater,  then  dilatation  ensues.  It  is  not  often  that  dilatation  is 
seen  from  hemorrhage  into  this  seat,  on  account  of  the  great  importance 
of  the  structures  in  the  immediate  vicinity,  a  comparatively  small  lesion 
producing  a  fatal  result. 

Both  pupils  dilated  and  fixed  from  very  large  unilateral  lesions.  In  other 
instances  both  pupils  were  dilated  and  fixed,  the  lesion  being  unilateral, 
though  indirectly  the  opposite  side  of  the  brain  was  implicated.  Six 
cases  of  this  kind  were  observed.  All  of  them  had  sustained  fracture 
through  the  middle  fossa  with  rupture  of  the  middle  meningeal  artery 
or  one  of  its  branches,  from  which  extensive  unilateral  extravasation  of 
blood  had  taken  place.  In  a  general  way,  these  fractures  may  be  de- 
scribed as  extending  from  the  base  to  above  the  level  of  the  parietal 
protuberance,  and  the  extravasated  blood  from  the  base  of  the  anterior 
fossa  to  the  posterior  part  of  the  middle  fossa.  The  pressure  was 
greatest  opposite  the  middle  lobe,  the  prominences  of  the  convolutions 
being  there  effaced,  and  the  outer  wall  of  the  lateral  ventricles  being 
flattened.  In  at  least  three  of  these  the  opposite  hemisphere  was 
involved  directly  by  the  pressure  which  was  communicated  through  the 
falx  cerebri,  a  slight  concavity  on  the  inner  side  of  the  opposite  cerebrum 
indicating  the  seat  of  pressure.  The  opposite  hemisphere,  from  the  one 
flattened  by  direct  contact  with  the  blood  clot,  would  likewise  have  been 
affected  by  the  increased  amount  of  cerebrospinal  fluid  displaced  by 
the  blood  clot  from  the  other  hemisphere,  though  the  pressure  from  this 


1  M.  Jordan  states  that  "dilatation  and  total  immobility  of  the  pupils  on  the  approach  of  a  lighted 
candle  is  one  proof  of  great  engorgement  of  the  brain  in  apoplexy."    Diet,  des  Sc.  Med.,  1878. 


138     MACEWEN,  PUPIL   IN   ITS  SEMEIO  LOGIC  AL  ASPECTS. 


cause  could  not  be  great,  distributed  as  it  would  be  over  the  whole 
cerebro-spinal  axis.  In  these  instances  the  patients  survived  the  injury 
by  only  a  few  hours,  during  which  they  were  plunged  in  profound  coma, 
and  therefore  it  is  possible  that  the  dilatation  of  the  pupil  on  the  side 
opposite  the  lesion  might  have  resulted  from  suppression  of  brain  func- 
tion (concussion)  on  that  side ;  though  it  is  probable  that  the  pressure 
communicated  from  the  lesion  in  itself  exercised  a  powerful  action.  It 
is  further  possible  that  the  ablation  of  function  by  pressure  of  the  white 
fibres  of  the  centre  of  the  hemisphere  would  in  itself  have  produced  the 
paralytic  mydriasis  of  the  opposite  side,  though  this  is  much  more  prone 
to  occur  when  the  blood  is  extravasated  into  the  interior  of  the  brain. 

One  pupil  dilated  and  fixed,  the  other  contracted,  accompanied  by  lesions 
on  both  hemispheres.  A  few  instances  occurred  in  which,  with  lesions  on 
both  sides  of  the  brain,  one  pupil  was  in  a  state  of  extreme  dilatation 
with  fixity,  the  other  was  contracted  and  fixed.  In  the  first  instance  of 
this  kind,  there  was  a  clot  weighing  not  quite  half  an  ounce  on  the  ex- 
ternal surface  of  the  dura  mater,  over  the  right  hemisphere,  opposite  the 
anterior  ascending  convolution,  while  there  was  extensive  laceration  of 
the  middle  lobe  of  the  left  hemisphere,  with  its  accompanying  extrava- 
sation of  blood.  The  patient  was  insensible,  and  lived  for  eighteen  hours. 
The  left  pupil  was  widely  dilated  and  fixed,  the  right  was  contracted 
and  fixed.  The  function  of  the  left  hemisphere  had  been  abolished, 
while  that  of  the  right  had  only  been  partially  interfered  with.  In  the 
second  instance  there  wTas  slight  laceration  of  the  cortical  substance, 
principally  on  the  base  of  the  first  and  second  left  frontal  convolutions, 
with  its  accompanying  extravasation;  while  on  the  right  side  there  was 
an  extensive  blood  clot  which  filled  the  subdural  space,  the  dura  mater 
having  been  ruptured  by  a  spiculum  of  bone  which  had  penetrated  a 
branch  of  the  middle  meningeal.  The  patient  was  insensible,  surviving 
the  accident  by  only  four  hours.  During  life  the  right  pupil  was  dilated, 
and  the  left  wTas  contracted,  both  being  fixed.  In  the  third  case  there 
was  an  extra-dural  clot  of  blood  weighing  three  ounces,  situated  princi- 
pally over  the  outer  portion  of  the  left  middle  fossa ;  while  on  the  right 
side,  at  the  junction  of  the  parietal  with  the  occipital  bone,  near  the 
vertex,  there  was  a  small  depressed  fracture,  an  osseous  spiculum  having 
penetrated  the  dura  mater.  This  patient  was  insensible,  and  lived  about 
forty-eight  hours  afterward.  He  had  other  bodily  injuries  of  a  severe 
kind,  which,  however,  did  not  exercise  any  material  effect  on  the  brain- 
function.  The  right  pupil  was  slightly  contracted  and  very  sluggish, 
while  the  left  was  dilated  and  fixed.  In  the  fourth,  there  was  a  very 
thin  diffuse  layer  of  blood  spread  over  the  surface  of  the  pia  mater 
covering  the  convolutions  in  the  anterior  portion  of  the  middle  lobe  of 
the  left  hemisphere;  while  on  the  right  hemisphere  there  was  an  exten- 
sive laceration  and  extravasation  into  its  middle  and  posterior  lobes. 


MACE  WEN,  PUPIL   IN   ITS   SEMEIOLOG-ICAL  ASPECTS. 


139 


Patient  lived  a  few  hours  after  the  accident,  during  which  he  was  in- 
sensible. The  right  pupil  was  dilated  and  fixed,  while  the  left  was 
slightly  contracted  and  sluggish.  Some  would  ascribe  these  results  to 
irritation  and  paralysis  respectively  of  the  oculomotor ;  while  others 
would  look  upon  them  as  due  to  vascular  changes  in  connection  with  the 
cerebral  lesions. 

One  pupil  dilated  and  fixed,  the  other  normal.  Many  instances  have 
been  observed  of  dilatation  and  fixity  of  one  pupil,  while  its  fellow,  per- 
haps with  the  exception  of  a  little  sluggishness  of  movement,  remained 
normal.  These  were  all  cases  of  fracture  of  the  middle  fossa  of  the  skull, 
and  in  comparatively  few  of  them  was  the  diagnosis  verified  by  post- 
mortem examination,  though  little  doubt  could  exist  as  to  the  lesion 
when  accompanied,  as  they  were,  by  the  usual  phenomena  of  hemorrhage 
from  the  ear,  followed  by  discharge  of  cerebro-spinal  fluid,  ptosis,  occa- 
sionally external  strabismus,  facial  hemiplegia,  and  paralysis  of  mem- 
bers. In  such  the  patient  was  generally  insensible  at  the  outset  when 
both  pupils  were  dilated  and  fixed.  As  the  patient  recovered  conscious- 
ness, one  pupil  became  normal  while  the  other  remained  dilated  and 
fixed,  this  being  on  the  side  of  the  lesion.  In  some  of  these  the  visual 
power  on  the  same  side  as  the  dilated  pupil  was  in  abeyence ;  in  others, 
it  was  imperfect,  and  in  a  few  it  was  almost  normal.  The  pressure  ex- 
ercised by  the  blood-clot  must  have  been  sufficiently  great  to  place  in 
abeyance  the  function  of  the  greater  part  of  the  affected  hemisphere,  as 
evidenced  by  the  complete  paralysis  of  the  opposite  member,  the  inter- 
ference with  vision,  and  the  evident  effect  upon  the  third  nerve.  In 
those  cases  in  which  post-mortem  examinations  were  obtained,  the  basal 
fracture  was  continued  into  or  toward  the  vertex,  and  the  clot  in  most 
instances  occupied  the  whole  of  the  middle  fossa  from  the  petrous  portion 
of  the  temporal  to  the  vertex,  the  convolutions,  especially  the  ascending, 
being  considerably  compressed.  The  opposite  hemisphere  was  in  almost 
a  normal  condition.  In  those  that  recovered,  the  dilatation  gave  way 
slowly,  and  was  followed  by  a  degree  of  contraction  along  with  sluggish- 
ness of  movement  which  ultimately  passed  off ;  though  in  one  case  it  still 
remained  small  and  sluggish  at  the  termination  of  the  fifth  month  from 
the  date  of  the  accident.  These  changes  were  evidently  determined  by 
the  gradual  absorption  of  the  blood-clot.  It  is  more  than  likely  that  in 
most  of  them  the  third  as  well  as  the  seventh  nerve  was  paralyzed,  and 
in  one  or  two  instances  the  fifth  in  addition,  as  indicated  by  the  loss  of 
sensation  on  the  affected  side.  Occasionally  the  second  was  interfered 
with.  Hearing  was  generally  much  affected,  if  not  absolutely  in  abey- 
ance on  the  affected  side,  during  the  early  months,  mechanical  obstruc- 
tion by  blood-clot  producing  loss  of  hearing  as  well  as  interference  with 
the  nerve. 

Pupil  contracted  on  only  one  side.    Quite  a  number  of  cases  have  been 


140     MACEWEN,  PUPIL  IN   ITS   SEMEIOLOG-ICAL  ASPECTS. 


observed  by  the  writer  in  which,  while  one  pupil  was  normal,  its  fellow 
was  contracted  and  fixed,  and  where,  judging  from  other  symptoms,  a 
cerebral  cortical  lesion  was  diagnosticated  as  existing  on  the  same  side  as 
the  affected  pupil.  In  at  least  three  of  these  instances  the  diagnosis  was 
verified  by  demonstration  of  the  lesion  on  the  operating  table,  and  by 
the  fact  that  its  removal  wTas  followed  either  by  great  amelioration  of 
the  state  of  contraction,  or  by  its  complete  relief.  One  was  a  case  of 
fibrous  tumor  of  the  dura  mater,  situated  over  the  left  anterior  lobe, 
which  exercised  pressure  on  the  surface  of  the  first  and  second  frontal 
convolutions.  The  pupil  on  the  same  side  as  the  lesion  was  minutely 
contracted  and  fixed.  Operation  was  demanded  for  epileptoid  seizures. 
The  turner  was  removed,  and  the  patient  recovered.  The  activity  of  the 
pupil  very  soon  returned,  and  the  contraction  was  in  great  measure  re- 
moved within  a  few  days  subsequent  to  the  operation.  Ultimately  the 
two  pupils  acted  alike.  The  second  was  a  case  in  which  there  was  a 
cortical  extravasation  of  blood  from  a  bruise  of  the  ascending  frontal 
convolution,  and  which  was  surrounded  by  an  area  of  irritation.  The 
pupil  on  the  same  side  was  contracted  and  fixed.  The  lesion  was  re- 
moved by  operation.  The  patient  recovered,  and  the  contraction,  though 
at  first  remaining  to  a  slight  extent,  disappeared  completely  within  a 
month.  In  the  third  instance,  the  dura  mater  over  the  right  frontal  re- 
gion was  punctured  by  an  osseous  spiculum.  The  pupil  of  the  correspond- 
ing side  was  minutely  contracted.  On  the  removal  of  the  fragment  of 
bone,  and  the  escape  of  a  small  quantity  of  fluid  blood  from  under  the 
dura  mater,  the  contraction  of  the  pupillary  sphincter  relaxed  imme- 
diately. Four  hours  afterward  the  pupil  responded  slowly  to  alternate 
light  and  shade.  Two  days  after  operation  it  was  quite  normal.  There 
are  many  explanations  advanced  for  such  pupillary  effects  arising  from 
these  lesions.  The  influence  of  the  dura  mater  on  the  basal  nerves  has 
to  be  borne  in  mind,  especially  when  it  is  inflamed ;  also  that  of  the 
possible  effect  which  might  be  transmitted  through  the  fibres  of  origin  of 
the  optic  to  its  centre,  and  so  to  the  third  nerve  ;  and,  again,  the  effects 
of  irritation  arising  from  pressure  exercised  on  the  two  alleged  centres 
of  pupillary  movement  in  the  cerebral  cortex.  All  of  them  could,  how- 
ever, be  more  directly  explained  by  vascular  changes  accompanying 
these  lesions  producing  their  effects  upon  the  vessels  of  the  eyeball. 

It  is  interesting  to  note  that  in  cerebral  softening  the  action  is  like 
that  of  hemorrhage  into  the  brain,  producing  abolition  of  function  and 
dilatation  of  the  pupil.  In  some  such  cases  there  is  no  doubt  that  the 
oculomotor  nerve  has  also  lost  its  power,  as  indicated  by  the  loss  of 
ocular  movement ;  but  in  others  the  movements  are  retained,  the  pupil, 
however,  being  dilated. 

The  effects  of  spinal  lesions  on  the  pupil.  There  have  been  very  many 
instances  under  personal  observation  of  spinal  irritation  inducing  labile 


M  A  CE  WEN,  PUPIL  IN  ITS   SEMEIOLOGIC  AL  ASPECTS. 


141 


mydriasis,  and  there  have  been  a  few  of  complete  lesion  of  the  cord 
causing  stabile  myosis.  Of  the  latter,  one  occurred  in  a  man  of  fifty 
years,  the  subject  of  a  sarcoma  involving  the  bodies  of  the  lower  cervical 
vertebra  pressing  upon  the  spinal  cord  and  ultimately  crushing  it.  The 
pupils  were  about  two  millimetres  in  diameter,  and  fixed.  The  vessels 
of  the  head  and  face  were  dilated,  and  the  conjunctivae  were  suffused. 
One  was  a  child,  aged  five  years,  affected  with  tubercular  infiltration  and 
destruction  of  the  bodies  of  the  third,  fourth,  and  fifth  cervical  vertebra, 
opening  up  the  canal  and  exposing  its  contents.  An  abscess  formed, 
which  involved  a  limited  area  of  the  spinal  canal  opposite  the  affected 
vertebra.  The  anterior  portion  of  the  theca  was  represented  by  a  fun- 
gated  process  of  granulation  tissue;  the  cord  was  in  a  much  softened 
condition,  and  was  surrounded  with  pus.  The  pupils,  which  for  months 
had  been  in  a  state  of  labile  mydriasis,  became,  during  some  days  prior 
to  death,  contracted  to  two  and  a  half  millimetres  in  diameter.  Several 
traumatic  lesions  of  the  cord  in  the  upper  dorsal  and  lower  cervical 
vertebrae  have  been  observed,  accompanied  by  myosis,  the  contraction 
being  from  two  to  three  millimetres.  In  each  of  those  death  ensued 
within  some  hours  or  days  from  date  of  injury.  In  all  there  was  destruc- 
tion of  the  cord  at  the  seat  of  injury;  in  some,  to  the  extent  of  severance 
of  almost  its  entire  calibre. 

In  the  foregoing  there  is  sufficient  evidence  to  show  that  the  sus- 
pension or  abolition  of  cerebral  function  in  the  living  body  is  attended 
by  mydriasis,  the  latter  being  the  sequent  of  the  former.  If 
inquiry  be  made  concerning  the  mechanism  inducing  this  pupillary 
effect  coincident  with  the  arrest  of  cerebral  function,  the  theory  which 
explains  the  greater  part,  if  not  the  whole  of  the  phenomena,  is  that 
which  has  been  so  ably  advocated  by  Mosso.  The  passive  movements 
of  the  pupil  are  regulated  by  the  vascular  system  of  the  iris,  which  is  in 
complete  harmony  with  that  of  the  encephalon.  In  those  conditions 
inducing  general  suspension  of  the  cerebral  function,  a  state  of  ischemia 
prevails  in  the  brain  and  iris  inducing  mydriasis.  .  This,  likewise, 
obtains  in  unilateral  lesions,  where  the  pressure  is  so  great  as  to  induce 
anaemia  of  brain  and  iris.  Myosis  may  also  be  brought  about  by  a  like 
mechanism  acting  in  the  opposite  direction.  The  "irritation"  setting 
up  congestion  of  the  cerebral  and  meningeal  vessels,  leads  to  congestion 
of  the  vessels  of  the  iris,  and  so  produces  contraction  of  the  pupil. 

When  investigating  the  cause  of  a  given  pupillary  state,  this  should 
be  done  in  a  methodical  manner,  examining  the  various  sources  control- 
ling pupillary  movements,  and  eliminating  those  which  do  not  apply. 
The  examination  ought  to  be  conducted  by  answering,  seriatim,  the  fol- 
lowing questions: 

1st.  Is  the  pupillary  condition  due  to  the  local  or  constitutional  action 
of  any  drug? 


142     MACE  WEN,  PUPIL  IN"  ITS   SEMEIOLOGICAL  ASPECTS. 

2d.  Is  the  state  of  the  pupil  dependent  upon  any  local  ocular  lesion 
or  optical  defect  (including  artificial  eyes)  ? 

3d.  Is  it  due  to  any  spinal  or  sympathetic  lesion,  more  especially  of 
the  cilio-spinal  region  and  the  cervical  sympathetic? 

4th.  Is  it  dependent  upon  any  localized  cerebral  lesion  affecting  special 
brain  centres — i.  e.,  corpora  quadrigemina,  optic  thalamus,  or  the  origin 
and  intracranial  course  of  the  second,  third,  and  fifth  nerves,  especially 
the  third  ? 

5th.  If  due  to  none  of  the  above,  the  probability  is  that  it  depends 
upon  either  a  suspension  of  brain  function  or  to  some  cerebral  "irrita- 
tion," in  either  case  inducing  vascular  changes  in  the  encephalon 
and  iris. 

The  following  points,  among  others,  may  be  formulated  from  the  fore- 
going: 

(A)  1.  When  the  function  of  the  brain  is  in  abeyance,  the  pupils  are 
in  a  state  of  stabile  mydriasis. 

2.  This  may  arise  either  from  temporary  suspension  or  from  abolition 
of  function. 

3.  Temporary  suspension  is  illustrated  by  shock,  and  the  effect  of  some 
poisons;  while  the  abolition  of  function  is  exemplified  by  extensive 
laceration  and  compression  of  the  brain. 

(B)  4.  When  the  function  of  the  brain  is  interfered  with  by  condi- 
tions usually  included  under  the  term  "irritation,"  the  pupils  are  in  a 
state  of  myosis ;  sometimes  labile,  but  generally  stabile  myosis. 

5.  This  "  irritation "  or  interruption  of  function  may  be  seen  during 
certain  degrees  of  cerebral  anaemia,  produced  experimentally,  and  not 
as  a  pathological  result ;  certain  amounts  of  brain  pressure,  and  certain 
stages  of  intracranial  inflammation. 

6.  These  are  illustrated  in  persons  who  have  suddenly  lost  a  consider- 
able quantity  of  blood  (about  a  fifth  of  the  whole) ;  in  the  growth  of 
intracranial  tumors  and  the  formation  of  sanguinolent  serous  and  puru- 
lent effusions,  when  the  degree  of  pressure  may  be  denominated  as  "me- 
dium," and  at  certain  periods  of  meningitis  and  encephalitis. 

(C)  7.  The  same  pathological  factors  which  cause  myosis  may  also 
cause  mydriasis,  the  degree  in  which  these  factors  are  present  being  the 
determining  point  between  the  former  and  the  latter,  and  not  merely  the 
particular  locus  in  the  brain. 

8.  It  is  well  illustrated  by  cases  where  the  hemorrhage  is  repeated, 
and  is  finally  pushed  to  syncope;  in  intracranial  pressure,  which  is  grad- 
ually increased  until  it  becomes  great,  such  as  arises  from  tumors,  blood 
clots,  and  inflammatory  products. 

(D)  9.  When  the  function  of  one-half  of  the  cerebrum  is  placed  in 
abeyance  by  a  superficial  or  cortical  lesion,  the  pupil  on  the  same  side 
as  the  lesion  is  in  a  state  of  stabile  mydriasis. 


MACEWEN,  PUPIL  IN   ITS   SEMEIO LOGICAL  ASPECTS.  143 


10.  This  is  well  illustrated  in  cases  of  intracranial  sanguinolent  effu- 
sion consequent  on  injury  (see  list  of  cases). 

(E)  11.  When  the  function  of  one-half  of  the  cerebrum  is  interfered 
with  by  some  source  of  cortical  irritation,  the  pupil  on  the  corresponding 
side  to  the  lesion  is  in  a  state  of  myosis. 

12.  This  is  illustrated  by  traumatic  and  pathological  lesions  affecting 
the  cortex  of  the  cerebrum  (see  list  of  cases). 

(F;  13.  Hemorrhage  into  the  pons  Varolii  when  small,  causes  strongly 
contracted  pupils ;  but  when  it  is  more  extensive,  involving  the  gray 
matter  beneath  the  aqueduct  of  Sylvius,  a  state  of  stabile  mydriasis  is 
induced. 

14.  Effusions  into  the  lateral  ventricles  when  small,  produce  con- 
traction of  the  pupils,  but  when  the  effusion  is  great  stabile  mydriasis 
ensues. 

15.  Inequality  of  the  pupils  indicates  a  unilateral  lesion  or  lesions. 

16.  When  the  lesion  is  cortical  and  unilateral  the  pupillary  manifes- 
tations are  on  the  corresponding  side.  When  the  basal  nerves  are 
affected  unilaterally  the  pupillary  effect  is  manifested  on  the  same  side 
as  the  lesion.  When  the  lesi  n  is  unilateral  and  affects  the  function  of 
the  white  fibres  of  the  cerebrum  the  opposite  pupil  is  generally  affected. 
When  the  basal  ganglia  are  implicated  unilaterally  the  pupil  is  some- 
times affected  on  the  same  side  as  the  lesion,  occasionally  on  the  other 
side. 

In  a  case  of  cholesteatoma  and  in  another  of  glioma  of  the  right  optic 
thalamus,  dilatation  of  the  left  pupil  was  found  {Boss,  vol.  ii.  p.  572). 

In  lesions  of  the  cerebral  peduncles  the  pupil  is  affected  on  the  same 
side  as  the  lesion. 

Lesions  in  the  corpora  quadrigemina  affect  both  pupils,  irritation1 
causing  contraction,  destruction  causing  dilatation  and  immobility. 

Section  or  destruction  of  one  optic  tract,  causes  dilatation  of  the 
opposite  pupil  and  blindness  of  the  opposite  eye. 

17.  Irritation  of  the  cord,  especially  the  cilio-spinal  axis,  produces 
dilatation  of  the  pupils,  while  destruction  of  the  cord  causes  contraction. 
These  effects  are  generally  seen  in  both  pupils,  though,  experimentally 
at  least,  they  may  be  confined  to  the  same  side  as  the  lesion. 

18.  The  pupils  are  affected  in  the  same  way  by  lesions  of  the  sympa- 
thetic, though  in  unilateral  lesions  it  is  only  the  pupil  on  the  same  side 
as  the  lesion  which  is  affected. 

19.  Speaking  generally,  when  myosis  is  due  to  a  cerebral  cause,  it 
indicates  the  earlier  stages  of  various  affections;  when  due  to  a  spinal 

1  Unilateral  electrical  stimulation  causes  dilatation  of  both  pupils,  the  opposite  one  becoming  first 
dilated.  Ferrier  explains  this  as  the  result  of  irritation  of  a  sensory  structure,  in  tliis  case  at-ting 
through  the  medium  of  the  anterior  roots  of  the  second  dorsal  nerves  which  ascend  in  the  cervicul 
sympathetic. 


144     MACE  WEN,  PUPIL   IN   ITS  SEMEIOLOGICAL  ASPECTS. 


lesion,  it  points  to  a  most  serious  paralysis,  often  to  the  destruction  of 
the  part.  When  mydriasis  arises  from  a  cerebral  lesion  it  is  generally 
present  in  large  amount ;  when  due  to  a  spinal  affection  it  indicates  irri- 
tation of  the  part. 

Myosis  Occurs  under  the  Following  Conditions  : 

1.  When  a  bright  light  acts  upon  the  retina. 

2.  Accommodation  for  a  near  object. 

3.  Rotation  of  the  eyeball  inward. 

4.  Local  irritation  or  painful  affections  of  the  eyeball. 

5.  Irritation  of  the  oculomotor  nerve. 

6.  Paralysis  of  sympathetic  roots  of  lenticular  ganglion  or  trunk  of 
sympathetic  in  the  neck.  In  paralysis  of  the  fifth  there  is  myosis  and 
inflammatiou  passing  on  to  destruction  of  the  eyeball. 

7.  Paralysis  of  the  ciliospinal  region  of  spinal  cord.  All  affections 
which  destroy  the  cervical  spinal  marrow  and  intercept  its  conductibility 
produce  congestion  of  the  face  and  contraction  of  the  pupils.  In  neurosis, 
which  suspends  or  diminishes  the  tone  of  the  sympathetic  or  spinal  axis. 

8.  Encephalic  congestion,  such  as :  obstacle  to  return  of  blood  in 
jugulars ;  venous  congestion  due  to  cardiac  causes ;  active  hyperemia, 
plethora,  fevers,  pneumonia,  hepatitis,  etc. ;  when  animal  is  suspended 
by  the  heels ;  in  early  stages  of  meningitis  and  encephalitis ;  in  acute 
mania  with  marked  activity  of  the  cerebral  circulation ;  in  chronic 
mania  pupils  are  variable,  when  contracted  are  said  to  indicate  super- 
vention of  paralytic  dementia. 

9.  During  sleep  ;  some  believe  this  to  be  due  to  the  congestion  of 
the  cerebral  vessels  and  those  of  the  iris  (Mosso) ;  others,  to*  the  inward 
rotation  of  the  eyeball. 

10.  In  the  early  stages  of  cerebral  tumor. 

11.  In  small  hemorrhages  into  the  cerebellum.  In  irritation  of  the 
cerebellum,  contraction  of  the  pupil  on  same  side  as  lesion  ensues. 

12.  Electrical  stimulation  of  the  angular  gyrus  frequently  causes  con- 
traction of  the  pupil. 

13.  During  forced  expiration,  when  the  eye  is  at  the  same  time  passive. 
Also  generally  seen  during  the  period  of  apncea  in  Cheyne-Stokes  respi- 
ration. 

14.  Convulsions  arising  from  meningo-en cephalitis  are  said  to  be 
,  accompanied  by  myosis,  while  in  convulsions  due  to  epilepsy  and  in 

epileptiform  fits  they  are  usually  accompanied  by  mydriasis. 

15.  When  the  eye  contracts  on  accommodation  to  a  near  object,  yet 
does  not  contract  to  light,  this  indicates  a  lesion  situated  between  the 
corpora  quadrigemina  and  the  oculomotorius.  This  affection  is  known 
as  the  Argyle-Roberteon  symptom.  It  is  seen  in  locomotor  ataxia  and 
occurs  in  the  progressive  paralysis  of  the  insane. 

16.  During  ursemic  coma. 


MACETTEN,  PUPIL  IN   ITS   SEMEIOLO  GICAL  ASPECTS. 


145 


17.  Myotics:  physostigmine,  nicotine,  pilocarpine,  morphine, muscarine. 
Mydriasis  occurs  under  the  Following  Condition-  : 

1.  In  darkness  or  in  subdued  light. 

2.  Accommodation  for  distant  objects. 

3.  Rotation  of  the  eyeball  outward. 

4.  In  forced  movements  discharged  from  the  medulla :  vomiting, 
swallowing,  chewing,  forced  respiration. 

5.  Paralysis  of  the  oculomotor  (accompanied  or  not  by  immobility 
of  eyeball,  external  strabismus,  diplopia,  etc.). 

6.  Destruction  of  the  optic :  amaurosis.  When  unilateral,  associated 
movements  continue. 

7 .  Irritation  of  sympathetic :  powerful  impressions  on  sensory  nerves ; 
strong  moral  emotions,  mental  pain,  grief,  fear ;  neuralgia  of  the  fifth 
nerve. 

8.  Irritation  of  the  spinal  cord,  especially  ciliospinal  region. 

9.  Encephalic  ansemia  :  In  all  cases  where  there  is  reflex  contraction 
of  the  vessels  of  the  head  ;  when  loss  of  blood  from  the  body  is  excessive ; 
obstruction  of  the  carotid  arteries  ;  in  thrombosis  of  brain  sinuses  ;  dila- 
tation of  mesenteric  vessels  when  extreme ;  syncope,  intense  cold, 
rigors ;  dyscrasias  of  the  blood,  convalescence,  cachectic  conditions ; 
asphyxia,  epilepsy,  in  certain  stages  of  these  affections. 

10.  Pressure  of  cerebrum  when  great  in  amount,  as  from  hemorrhage, 
neoplasms,  etc.    In  the  last  stages  of  meningo-encephalitis. 

11.  In  cerebral  softening.  In  acute  dementia  (oedema  of  cortex 
cerebri)  observers  state  that  the  pupils  are  invariably  dilated  (Hutch- 
inson). * 

12.  In  idiots  the  pupils  are  generally  dilated. 

13.  During  deep  inspiration,  generally  in  respiratory  period  of  Cheyne- 
Stokes  breathing. 

14.  Hemorrhage  into  centrum  ovale  and  into  cerebral  peduncles. 

15.  Ferrier  produced  dilatation  of  opposite  pupil  by  destructive  lesion 
of  the  optic  tract  in  the  thalamus,  indicative  of  rupture  of  the  centripetal 
fibres  to  the  irido-motor  nucleus  in  the  floor  of  the  Sylvian  aqueduct. 

16.  In  hydrophobia  there  is  mydriasis. 

17.  Mydriatics :  atropine,  homatropine,  duboisine,  daturine,  hyoscya- 
mine.  Curare  injected  subcutaneously  in  animals  i^five  to  ten  centi- 
grammes) induces  in  one  or  two  hours  complete  paralysis  of  the  third 
nerve. 

The  Effect  on  the  Pupil  of  Local  Conditions  of  the  Eye- 
ball •} 

1.  Hyperemia  of  the  iris  produces  contraction  of  the  pupil  which 
darkness  scarcely  diminishes. 

1  The  writer  is  indebted  to  Dr.  Thomas  Reid  for  revising  this  list  of  pupillary  effects  occasioned  by 
local  conditions  of  the  eyeball. 

NO.  CLXXXVIT. — JULY,  1887.  10 


146     STERNBERG,  DEATH-POINT   OF  MICRO-ORGANISMS. 


2.  Presbyopia  and  hypermetropia  cause  contraction  of  the  pupils  in 
cases  where  continuous  and  excessive  strain  for  near  accommodation  has 
been  long  continued  and  has  produced  asthenopia. 

3.  Pupillary  atresia,  consequent  upon  chronic  irritation  with  posterior 
synechia,  producing  contraction  of  the  pupil. 

4.  In  synechia  total  dilatation  is  impossible,  the  iris  only  dilating 
where  free,  hence,  the  pupil  is  irregular.  If  the  synechia  is  annular  the 
pupil  is  both  contracted  and  immobile. 

5.  In  microria  there  is  a  congenital  state  of  extreme  contraction. 

6.  In  glaucoma  the  pupil  is  dilated,  contracting  little  or  not  at  all  to 
the  action  of  calabar  bean. 

7.  In  coloboma,  both  in  the  congenital  form  and  after  iridectomy,  there 
are  irregularity  and  immobility  of  the  pupil. 

8.  In  idiopathic  mydriasis  there  is  little  contraction  to  the  action  of 
light  or  to  myotics. 

9.  In  certain  cases  of  amblyopia  and  amaurosis  there  is  dilatation  of 
the  pupil. 

10.  In  hippus  pupillse  there  are  alternate  contraction  and  dilatation 
often  accompanied  by  nystagmus. 

11.  Inequality  of  the  pupils  exists  in  some  who  have  different  degrees 
of  refraction  in  the  two  eyes,  one  being  emmetropic  and  the  other  myopic. 


THE  THERMAL  DEATH-POINT  OF  PATHOGENIC  ORGANISMS. 
By  George  M.  Sternberg,  M.D., 

MAJOR  AND  SURGEON  XT.  S.  ARMY. 

An  exact  knowledge  of  the  thermal  death-point  of  pathogenic  organ- 
isms is  desirable,  both  as  a  matter  of  general  scientific  interest,  and  from 
a  practical  point  of  view.  As  biologists,  we  wish  to  knoAV  whether  the 
vital  properties  of  the  living  protoplasm  contained  in  the  minute  veget- 
able organisms  in  question  are  destroyed  at  a  uniform  temperature,  and 
if  so  at  what  temperature  ;  or  whether  there  is  a  considerable  range  in 
the  limits  of  vital  resistance  to  heat  exhibited  by  different  organisms  of 
this  class.  As  sanitarians,  we  wish  to  know  what  temperature  can  be 
relied  upon  for  the  destruction  of  disease  germs  in  the  excreta  of  patients 
suffering  from  typhoid  fever,  from  cholera,  and  from  other  infectious  dis- 
eases transmitted  by  means  of  the  alvine  discharges  of  the  sick;  whether 
boiling  of  infected  clothing,  or  of  drinking  water  contaminated  with  dis- 
ease germs,  is  a  safe  means  of  disinfection,  etc. 

Various  experimenters  have  recorded  observations  with  reference  to 
the  thermal  death-point  of  different  microorganisms,  but,  so  far  as  I 


STERNBERG,  DEATH-POINT   OF    MICRO-ORGANISMS.  147 

know,  no  one  has  heretofore  made  an  extended  inquiry,  by  means  of  a 
uniform  method,  with  a  view  to  determining  the  vital  resistance  to  heat 
of  the  considerable  number  of  pathogenic  organisms  now  known  to  bac- 
teriologists. 

All  of  the  experiments  recorded  in  the  present  paper  relate  to  moist 
heat — that  is  to  say,  the  test-organisms  have  in  every  case  been  in  a  moist 
condition,  in  fluid  cultures.  The  effect  of  dry  heat  upon  desiccated  or- 
ganisms is  quite  another  question.  This  has  been  studied  by  Koch  and 
Wolffhiigel,1  who  have  summarized  the  results  of  their  experimental 
work  as  follows : 

"1.  A  temperature  of  100°  C.  (212°  F. ),  maintained  for  one  hour  and  a 
half,  will  destroy  bacteria  which  do  not  contain  spores. 

"  2.  Spores  of  mould-fungi  require  for  their  destruction  in  hot  air  a  tem- 
perature of  from  110°-115°  C.  (230-239°  F.),  maintained  for  one  hour  and  a 
half. 

"  3.  Bacillus  spores  require  for  their  destruction  in  hot  air  a  temperature  of 
140°  C.  (284°  F.),  maintained  for  three  hours."    (Op.  cit.,  p.  231.) 

In  my  experiments  I  have  adopted  ten  minutes  as  the  standard  time 
of  exposure  to  a  given  degree  of  temperature. 

A  fresh  culture  of  the  organism  to  be  tested  is  introduced  into  capil- 
lary glass  tubes  which  have  an  expanded  extremity  to  serve  as  an  air 
chamber,  by  means  of  which  the  culture  fluid  is  drawn  into  or  forced 
out  of  the  capillary  tube.  This  is  readily  accomplished  by  heating  the 
little  bulb. 

The  glass  tubes,  hermetically  sealed,  are  introduced  into  a  vessel  con- 
taining water,  which  is  kept  at  a  uniform  temperature  by  personal 
supervision,  a  Bunsen  burner  being  the  source  of  heat.  A  standard 
thermometer  is  placed  in  the  vessel,  and  this  and  the  capillary  tubes 
are  protected  from  the  bottom  of  the  vessel  containing  them  by  a  thick 
plate  of  glass.  A  uniform  temperature  throughout  the  fluid  is  main- 
tained by  stirring  it  with  a  glass  rod. 

After  exposure  for  ten  minutes  to  a  given  temperature  the  sealed  ex- 
tremity of  the  capillary  tube  is  broken  off  with  sterilized  forceps,  and 
the  contents  are  forced,  by  heating  the  air  in  the  expanded  extremity, 
into  a  test-tube  containing  sterile  flesh-peptone-gelatine,  which  has  been 
liquefied. by  exposure  in  a  water  bath  to  a  temperature  of  40°  C,  or 
below.  The  cotton  plug  is  only  removed  for  a  moment  in  order  to 
introduce  the  contents  of  the  capillary  tube,  and  in  my  extended  experi- 
ments I  have  very  rarely  seen  any  accidental  contamination.  A  rubber 
cap  is  next  placed  upon  the  open  end  of  the  test-tube  and  the  gelatine 
is  spread  in  a  uniform  manner  over  the  interior  of  the  tube  by  the 
method  of  Esmarch.2  This  is  accomplished  by  rolling  the  tube  in  iced 
water  until  the  gelatine  hardens. 


1  Mitth.  a  d.  kais.  Gesumlheitsamte,  Bd.  1. 

2  Zeitschrift  filr  Hygiene,  Bd  L,  Befl  2,  9  293 


148     STERNBERG,  DEATH-POINT   OF   MICRO  -  ORGANISMS. 


These  tubes  are  then  kept  at  a  temperature  a  little  below  the  melting 
point  of  gelatine — 20°  to  22°  C. — for  at  least  a  week.  If  the  test  organism 
has  not  been  killed  by  the  temperature  to  which  it  was  exposed  colonies 
are  developed  in  the  gelatine,  which  may  often  be  recognized  by  the 
naked  eye  within  a  day  or  two.  In  other  cases  development  is  retarded, 
and  it  is  only  at  the  end  of  four  or  five  days  that  evidence  of  growth  is 
seen.  The  absence  of  growth  at  the  end  of  eight  or  ten  days  is  taken  as 
evidence  that  the  vitality  of  the  test-organism  has  been  destroyed  by  the 
temperature  to  which  it  was  exposed.  In  every  case  a  control  experi- 
ment is  made  with  material  from  the  same  culture  which  has  not  been 
subjected  to  heat. 

Bacillus  of  Typhoid  Fever. — Since  the  publication  of  Gaffky's 
memoir,  in  the  second  volume  of  the  Mitth&ilungen  aus  dem  Kaiserlichen 
Gesiindheitsamte,  his  statements  with  reference  to  the  formation  of  spores 
by  the  typhoid  bacillus  have  been  generally  accepted,  and  have  been  con- 
firmed by  most  of  the  observers  who  have  followed  him.  Seitz,1  how- 
ever, has  not  been  able  to  convince  himself  of  the  presence  of  spores 
in  his  cultures.  Buchner2  and  Michael3  also  report  their  failure  to  find 
spores. 

Gaffky  states  that  spores  are  not  formed  at  the  room  temperature, 
but  that  they  are  developed  on  the  third  or  fourth  day  in  cultures  kept 
in  an  incubating  oven  at  37°  C.  These  spores  are  said  to  be  shining^ 
round  bodies,  which  occupy  the  whole  width  of  the  bacilli  and  are 
situated  only  at  the  ends  of  the  rods.  A  single  rod  is  said  to  contain 
but  one  well-developed  spore,  although,  according  to  Gaffky,  an  im- 
perfectly developed  spore  may  sometimes  be  seen  at  the  opposite  end  of 
a  rod  containing  a  perfect  spore. 

My  cultures  of  the  typhoid  bacillus  are  from  stock  brought  from 
Koch's  laboratory  by  Dr.  Meade  Bolton.  The  morphological  characters 
and  the  characteristic  growth  upon  potato  correspond  perfectly  with  the 
account  given  by  Gaffky  and  other  authorities,  and  leave  no  doubt  as 
to  the  identity  of  the  organism  which  has  served  for  my  experiments.  I 
have  repeatedly  seen  in  my  potato-cultures  which  had  been  kept  at  38° 
for  several  days,  shining,  spherical  bodies,  located  at  the  ends  of  the  rods, 
which  appear  to  be  spores,  and  which  I  supjDose  to  be  identical  with  the 
bodies  pronounced  by  Gaffky  to  be  spores.  But  these  bodies  stain  with 
fuchsin,  and  if  they  are  in  truth  reproductive  elements,  my  temperature  ex- 
periments show  that  their  vitality  is  destroyed  by  a  temperature  of  60°  C. 

As  my  own  previous  experiments  upon  spore-bearing  bacilli,  and  those 
of  other  experimenters,  indicated  that  spores  require  for  their  destruc- 
tion a  comparatively  high  temperature,  I  made  first  the  following  ex- 


1  Bakteriologische  Studien  zur  Typhus — Aetiologie,-l[iinchen,  1886. 

2  Archiv  f.  Hygiene,  vol.  iii.  p.  361.  3  Fortschr.  d.  Medicin,  18S6,  No.  11. 


STERNBERG,  DEATH-POINT  OF   MICRO  -  ORGANISMS.  149 


periments,  in  which  material  from  a  pure  culture  in  veal  broth  was 
exposed  for  the  time  adopted  as  a  standard  (ten  minutes),  as  follows : 
Nov.  10.    50°,  60°,  70°,  Cont. 

In  this,  and  in  all  subsequent  records  of  experiments  made,  the  figures 
in  heavy  type  indicate  that  growth  occurred ;  the  figures  in  light  type 
indicate  the  absence  of  growth — i.  e.,  the  killing  of  the  test  organism  by 
ten  minutes'  exposure  to  the  temperature  indicated  by  the  figures.  It 
will  be  seen  that  at  60°  and  at  70°  C.  no  growth  occurred,  while  in  the 
control  tube  and  in  that  at  50°  (=122°  Fahr.)the  typhoid  bacillus  grew 
abundantly.  My  object  has  been  to  determine  the  lowest  temperature 
which  will  insure  the  destruction  of  all  germs  of  each  species  tested.  I 
have  not  therefore  considered  it  necessary  to  count  the  number  of 
colonies  which  have  grown  out  in  the  Esmarch  tubes  in  those  cases 
where  the  temperature  has  been  insufficient  to  accomplish  the  object  in 
view.  Such  a  record  has  no  special  advantage  over  the  simple  record  of 
growrth  or  failure  to  grow.  In  the  practical  application  of  data  of  this 
kind  to  the  disinfection  of  typhoid  excreta,  etc.,  it  is  evident  that  a  few 
colonies,  representing  a  few  bacilli  or  spores,  which  have  survived  the 
temperature  tested,  are  as  potent  for  mischief  as  a  larger  number.  My 
experiments  upon  the  typhoid  bacillus  are  recorded  iu  the  following 
table: 

Typhoid  Bacillus. 

(Ten  minutes'  exposure.) 


Date. 

Culture  medium. 

Experiments. 

Remarks. 

1886. 
Nov.  10. 

Veal  broth. 

50°,  60,  70,  Cont. 

In  oven  at  38°  for  48  hours. 

Nov.  15. 

Veal  broth. 

50°,  52,  54,  56,  58,60,  Cont. 

Fluid  culture  of  November  1st. 

Nov.  30. 

Potato  culture, 

50°,  55,  60.  70,  80,  Cont. 

Culture  at  room  temperature. 

Dec.  4. 

Potato  culture, 

60°,  Cont. 

Culture  in  oven  at  38°  for  7  days. 

Dec.  24. 

1887. 
Jan.  15. 

Potato  culture, 
Potato  culture, 

60°,  70,  SO,  Cont. 
55°,  60,  70,  80,  Cont. 

Culture  in  oven  for  10  days,  then  kept 
at  room  temperature  for  15  days. 

Culture  in  oven  at  38°  for  7  days. 

Jan.  20. 

Potato  culture, 

48°,  50,  52,  60,  Cont. 

In  oven  at  38°  for  10  days. 

Jan.  21. 

Potato  culture, 

50°,  GO,  Cont. 

Potato  in  oven  7  days,  then  kept  at 
room  temperature  7  days. 

An  inspection  of  this  table  shows  that  no  development  occurred  in 
any  instance  after  exposure  to  a  temperature  of  56°  C.  and  above.  In 
one  experiment  (Nov.  30)  growth  occurred  after  exposure  to  55°  C,  but 
in  this  case  it  was  very  much  delayed  ;  in  the  experiment  of  January  15, 
no  development  occurred  after  exposure  to  55°.  Differences  of  this  kind 
when  we  are  on  the  border-line  are  to  be  expected. 

We  may  then  safely  say  that  the  thermal  death-point  of  the  typhoid 
bacillus  is  56°  C.  (=132.8°  F.). 


150     STERNBERG,  DEATH-POINT  OF  MICRO-ORGANISMS. 


Spirillum  of  Asiatic  Cholera  ("  Comma-bacillus  "  of  Koch). 
— My  experiments  have  been  made  simultaneously  upon  the  cholera 
spirillum  and  the  two  organisms  which  most  closely  resemble  it,  viz.,  the 
"  cheese  spirillum  "  of  Deneke  and  the  Finkler-Prior  spirillum. 

The  cultures  in  these  experiments  were  all  made  at  the  room  tempera- 
ture in  flesh-peptone-gelatine. 

When  development  was  retarded,  the  fact  is  indicated  in  the  tables  by 
a  star  following  the  figures  denoting  the  temperature. 


Date. 

Organism. 

Temperature  to  which  exposed 
ten  minutes. 

r 

Cholera  spirillum. 

42°,  44,  46,  48*,  Cont. 

December  30.  1886  .  . 

i 

•  •  -i 

Cheese  spirillum. 

42°,  44,  46,  48*,  Cont. 

i 

i 

Finkler-Prior  spirillum. 

42°,  44,  46,  48*,  Cont. 

In  this  first  experiment  no  growth  was  observed  in  the  Esmarch  tubes 
containing  the  three  organisms,  after  exposure  to  48°  for  ten  minutes,  for 
several  days  afrer  the  control  tubes  had  "broken  down,"  but  subse- 
quently a  few  colonies  developed  in  each  of  these  tubes.  This  consider- 
able retardation  of  growth  led  me  to  think  that  a  slightly  longer  ex- 
posure would  be  fatal  to  all  of  these  sprilla.  I  accordingly  made  the 
following  experiment  at  the  same  temperature,  but  varying  the  time  of 
exposure. 


Date.  Organism. 

1 

Temperature. 

Time  of  exposure  in  minutes. 

f  j  Cholera  spirillum. 

i ! 

January  7,  18S7  ■{     Cheese  spirillum 
1 

(_   Finkler-Prior  spirillum. 

4S°  C.  =  118.4°  F. 

2°,  4,  6,  8*,  10*,  12*. 
2°,  4,  6,  8*,  10*,  12*. 
2°,  4,  6,  8*,  10*,  12*. 

This  was  followed  by  a  similar  experiment  at  50°  C. 

Date. 

Organism. 

Temperature. 

Time  of  exposure  in  minutes. 

r 

1 

January  10,  1887  { 
1 

I 

Cholera  spirillum. 
Cheese  spirillum. 
Finkler-Prior  spirillum. 

50°  C.  =  122°  F. 

2°,  4,  6,   8*,  10*,  Cont. 
2°,  4,  6,   8*,  10*,  Cont. 
2°,  4,  6*,  S,     10,  Cont. 

In  this  experiment  only  a  few  colonies  developed  after  exposure  for 
eight  and  ten  minutes  in  the  case  of  the  cholera  and  of  the  cheese  spiril- 
lum, and  none  at  all  in  the  case  of  the  Finkler-Prior  spirillum. 


STERNBERG-,  DEATH-POINT   OF   MICRO-ORGANISMS.  151 


The  following  experiment  was  made  at  52°  C. 


Date. 

Organisms. 

Temperature. 

Time  of  exposure  in  minutes. 

Cholera  spirillum. 

52°  C.  =  125.6°  F. 

2°*,  4,  G,  8,  10,  Cont. 

January  31,  1887  j 

Cheese  spirillum. 

2°*,  4,  6,  8,  10,  Cont. 

Finkler-Prior  spirillum. 

2°,     4,  6,  8,  10,  Cont. 

It  will  be  noted  that  identical  results  were  obtained  throughout  with 
the  cholera  and  the  cheese  spirillum,  while  the  Finkler-Prior  spirillum 
proved  to  have  a  little  less  resisting  power  to  heat. 

The  following  experiment  gives  a  result  in  accord  with  the  above.  It 
was  made  for  the  purpose  of  testing  the  question  whether  a  difference 
would  be  shown  in  the  resisting  power  of  old  and  recent  cultures.  I 
may  remark  here  that  the  cholera  spirillum  retains  its  vitality  for  several 
months,  at  least,  in  cultures  which  are  kept  in  a  moist  condition.  On 
the  other  hand,  Koch  has  shown  that  it  is  quickly  destroyed  by  desic- 
cation. 


Date. 

Cholera  spirillum. 

Temperature 

Time  of  exposure  in  minutes. 

Fresh  culture. 

52°  C.  =  125.6°  F. 

2°*,  4,  6,  Cont. 

January  17,  1887^ 

Culture  13  days  old. 

2°*,  4,  6,  Cont. 

Anthrax  Bacillus. — Davaine  first  made  experiments  (1873)  to 
determine  the  temperature  required  to  destroy  the  vitality  of  the  anthrax 
bacillus  as  found  in  the  blood  of  an  animal  just  dead.  Under  these  cir- 
cumstances no  spores  are  present.  The  destruction  of  vitality  was  tested 
by  inoculation  into  susceptible  animals.  This  method  is  open  to  the 
objection  that  at  temperatures  approaching  that  which  destroys  vitality 
the  development  of  the  bacillus  is  retarded,  and  the  animal  is  likely  to 
suffer  a  non-fatal  attack  of  the  disease,  which  may  escape  observation. 
This  is  probably  the  explanation  of  the  slight  difference  in  the  results 
obtained  by  Davaine  and  those  of  Chauveau  made  more  recently. 


Authority. 

Temperature. 

Time  of  exposure. 

Remarks. 

Davaine 

48° 

15  minutes. 

In  hlood. 

Davaine 

50 

10  " 

Davaine 

55 

5 

Chauveau  . 

50 

20  " 

Cultures. 

Chauveau  . 

54 

10  " 

152     STERNBERG,  DEATH-POINT  OF  MICRO-ORGANISMS. 

According  to  Fliigge,  anthrax  spores  are  killed  by  exposure  to  100° 
C.  for  two  minutes.  In  a  recent  experiment  by  the  writer  a  single 
colony  developed  after  exposure  to  this  temperature  for  two  minutes,  but 
there  was  no  growth  when  the  time  was  extended  to  four  minutes. 

Bacillus  of  Glanders— Loffler1  has  recently  determined  the 
thermal  death-point  of  the  JRotz  bacillus.  He  finds  it  to  be  55°  C,  the 
time  of  exposure  being  ten  minutes. 

Bacillus  of  Swine  Plague  (German,  Sehweine  rothlauf;  French, 
Eouget).  Bacillus  of  Mouse  Septicemia  (Koch). — Pasteur's  bacillus 
of  rouget  is,  no  doubt,  identical  with  the  bacillus  of  Sehweine  rothlauf  of 
the  German  bacteriologists.  I  have  experimented  upon  cultures  from 
both  sources.  The  bacillus  of  mouse  septicaemia  is  also  supposed  by 
some  authors  to  be  identical  with  the  above.  According  to  Eisenberg, 
the  bacillus  of  mouse  septicaemia  forms  spores.  Fliigge  says  of  the 
bacillus  of  Sehweine  rothlauf: 

"  In  bouillon  cultures  which  have  been  kept  for  three  days  at  the  room 
temperature,  or  for  twenty-four  hours  at  40°,  one  notices  the  formation  of 
small  spherical  bodies,  which  probably  represent  spores ;  although,  on  account 
of  their  minuteness,  the  formation  and  development  of  these  bodies  have  not, 
up  to  the  present  time,  been  exactly  observed."  2 

My  experiments  upon  the  thermal  death-point  of  these  organisms  are 
included  in  the  following  tables. 


Cultures  in  Flesh-peptone-gelatine. 


Date. 

Organism. 

Temperature  to  which  exposed. 

January  20,  1887   

Mouse  septicaemia. 

Mouse  septicaemia. 
Sehweine  rothlauf. 

Mouse  septicaemia. 
Sehweine  rothlauf. 

Rouget. 

50°,  60,  Cont. 

52°,  54,  56*,  58,  Cont. 
52°,  54,  56,  Cont. 

60°,  Cont. 
60°,  Cont. 

54°,  56*,  58,  Cont. 
52°,  54,  56*,  58,  Cont. 

Cultures  in  Bouillon. 

Date. 

Organism. 

Temperature  to  which  exposed. 

March  17,  1887   

Rothlauf. 

Mouse  septicaemia. 

60°,  65,  Cont. 
60°,  65,  Cont. 

These  bouillon  cultures  were  kept  in  the  incubating  oven  at  38°  for 
three  days,  and  afterward  at  the  room  temperature  for  eight  days.  The 
bacilli  were  found  to  have  grown  out  into  slender  filaments,  which  pre- 


i  Arbeiten  a.  d.  Kaiserlichen  Gesundheitsamte,  Bd.  1,  Heft  5.         2  Die  Mikroorganismen,  p.  246. 


STERNBERG,  DEATH-POINT   OF   MICRO-ORGANISMS.  153 


sen  ted  the  appearance  of  having  vacant  places  in  their  protoplasm, 
which  possibly  represented  spores.  As  will  be  seen  by  reference  to  the 
table,  no  growth  occurred  after  exposure  to  a  temperature  of  60°  C.  for 
ten  minutes.  We  must,  therefore,  admit  either  that  this  bacillus  does 
not  form  spores  under  the  circumstances  stated  by  Fliigge,  or  that  the 
spores  are  destroyed  at  the  comparatively  low  temperature  named. 

In  the  following  table  I  include  several  species  of  pathogenic  and  non- 
pathogenic bacilli  in  which  the  question  of  spore-formation  has  not 
been  definitely  settled.  In  regard  to  the  first-named  (Emmerich's 
bacillus)  Eisenberg  remarks  "  spore-formation  not  yet  observed."  Ac- 
cording to  Fliigge,  B.  sputig.  crassus  "  appears  to  form  spores  at  a 
temperature  of  35°."  The  bacillus  of  blue  milk  is  said  by  Eisenberg 
to  form  spores  in  gelatine  cultures  after  the  third  day.  The  lactic  acid 
ferment  is  said  by  the  same  author  to  form  spores  at  the  ends  of  the 
rods,  which  appear  as  spherical,  shining,  highly  refractive  bodies.  In 
my  own  examinations  of  stained  cover-glass  preparations  from  the  cul- 
tures used  in  the  following  experiments,  I  have  in  no  instance  been  able 
to  satisfy  myself  of  the  presence  of  spores. 


Recent  Cultures  in  Flesh-peptone-gelatine. 


Organism. 

Date. 

Temperature  to  which  exposed  ten  minutes. 

Emmerich's  bacillus    .    .    .  .«| 

January  24, 
January  28, 
February  1, 

60°,  Cont. 

7<>°,  80,  90,  loo,  Cont. 

60°,  62,  64,  Cont. 

January  24, 
February  1, 

60°,  Cont. 

58°*,  .60*,  62°,  Cont. 

Friedlander's  bacillus     .    .  .1 
(So-called  '*  pneumo-coc-  1 
cus.")  1 

December  24, 
January  8, 
January  11, 
January  20, 

50°,  52*,  54*,  Cont. 
58°,  60,  62,  64,  Cont. 
54°,  56,*  58,  Cont. 
56°,  58,  Cont. 

Bacillus  sputig  crassus  .    .    ,  •< 
(Kreibohm.)  ( 

January  24, 
Jauuaiy  28, 
January  31, 

60°,  Cont. 

50°,  Cont. 

54°,  56,  58,  Cont. 

Bacillus  pyocyanus     ....  -J 
(Green  pus.)  y 

-  December  24, 
December  31, 
January  8, 
January  17, 
February  2, 

70°,  80,  Cont. 

46°,  48,  50,  Cont, 

58°,  60,  02,  64,  Cont. 
52°,  54*,  Cont. 
54°,  5b,  58,  Cont, 

January  21, 
January  25, 
January  2G, 
February  2, 

56°*,  60,  Cont. 
56°,  58,  Cont. 
,     520*,  54*(  5G)  Cont. 
54°,  56,  58°,  Cont. 

1 

Bacillus  prodigiosus    ....  J 
(Commonly  called  micro-  1 
coccus  prodigiosus.)  { 

January  21, 
January  25, 
January  20, 
February  2, 

56°,  60,  Cont. 

5U°,  58,  Cont. 

52°*,  54*,  56*,  Cont. 

54°*,  56,  58,  Cont. 

Bacillus  cyanogen  us   .    .    .    .  f 
(Bacillus  of  blue  milk.)  \ 

January  28, 
January  31, 

50°,  60,  Cont. 
54°,  56,  58,  Cont. 

Bacillus  fluorescens    .    .    .    .  j 

January  28, 
January  31, 

50°,  60,  Cont. 
54°,  56,  5S,  Cont. 

Bacillus  acidi  lactici  .    .    .    .  j 

January  24, 
January  20, 
February  1, 
February  8, 

60°*,  Cont. 
52°,  54,  56,  Cont. 
60°,  62,  64,  Cont. 
54°,  56,  58,  Cont 

154     STERNBERG,  DEATH-POINT   OF  MICRO-ORGANISMS. 


Potato  Cultures  in  Incubating  Oven  for  Three  Days,  at  38°, 
to  Test  for  Spores. 

(No  spores  seen  on  microscopic  examination  of  stained  cover-glass  preparations.) 


Organism. 

Date. 

Temperature  to  which  exposed. 

March  1,  1887. 

60°,  65,  Cont. 

60°,  65,  Cont. 

60°,  65,  Cont. 

CI  (< 

60°,  65,  Cont. 

Old  Cultures  in  Flesh-peptone-gelatine,  to  Test  for  Spores. 

(March  7,  1887.) 

Organism. 

Age  of  culture. 

Temperature  to  which  exposed. 

36  days. 

60°,  65,  Cont. 

43  « 

60°,  65,  Cont. 

46  « 

60°,  65,  Cont. 

42  " 

60°,  65,  Cont. 

Bacillus  cyanogenus  .       .  . 

33  " 

60°,  65,  Cont. 

42  " 

60°,  65,  Cont. 

It  will  be  seen  that  in  all  of  these  experiments  the  lactic  acid  ferment 
is  the  only  one  which  resisted  a  temperature  of  60°  C;  and  if  the  pres- 
ence of  spores  could  be  determined  by  this  test,  this  is  the  only  organism 
in  the  list  in  which  there  is  any  evidence  of  spore  formation.  I  am  not, 
however,  disposed  to  accept  this  test,  and  think  it  not  improbable  that 
some  of  the  bacilli  in  the  list  form  reproductive  spores,  which  differ  from 
those  of  the  anthrax  bacillus  and  certain  other  spore-forming  bacilli,  in 
the  fact  that  they  are  destroyed  at  a  comparatively  low  temperature. 
The  only  way  to  settle  this  question  will  be  by  the  method  of  direct 
observation.  If  the  refractive  spherical  bodies,  supposed  to  be  spores, 
which  may  be  seen  in  potato  cultures  of  the  typhoid  bacillus,  in  bouillon 
cultures  of  the  bacillus  of  swine  plague,  etc.,  are  observed  to  develop 
into  bacilli,  they  will  be  demonstrated  to  be  reproductive  elements,  or 
spores,  notwithstanding  the  fact  that  they  are  destroyed  by  so  low  a 
temperature  as  60 J  C. 

The  following  experiments  have  been  made  with  pathogenic  and  non- 
pathogenic bacilli  which  are  known  to  form  spores. 


STERNBERG,  DE  AT  H-POINT  OF    MICRO-ORGANISMS.  155 


Organism. 

Date. 

Temperature  to  which  exposed 
ten  minutes. 

Bacillus  alvei  (foul  brood  of  bees)     .       .  j 

December  8, 
December  30, 

80°,  Cont. 
90°,  lou,  Cont. 

January  24, 
January  28, 

60°,  Cont. 

70°,  80,  90,  Cont. 

December  28, 
December  31, 

80°,  Cont. 
90°,  100,  Cont. 

The  following  experiments  have  been  made  upon  these  spore-forming 
bacilli  at  a  temperature  of  100°  C.  (212°  F.).  the  time  of  exposure  being 
varied. 

Organism. 

Date. 

Time  of  exposure  in  minutes. 

February  9, 

2*,  4,  6,  8,  10,  Cont. 
*  A  single  colony. 

February  9, 

2*,  4,  6,  8,  10,  Cont. 
*  A  few  colonies. 

February  9, 

2,    4,  6,  8,  10,  Cont. 

Marcb  4, 

2*,  4,  6,  8,  10,  Cont. 
*  A  single  colony. 

Bacillus  Tuberculosis. — Schill  and  Fischer  (1884),  assuming  that 
the  tubercle  bacillus  forms  spores,  made  quite  a  number  of  experiments 
to  determine  its  thermal  death-point.  Using  fresh  sputum  as  the  material, 
and  testing  the  destruction  of  the  vitality  of  the  bacilli  contained  in 
this  material  by  inoculations  into  guinea-pigs,  they  found  that  exposure 
to  a  temperature  of  100°  C,  in  steam,  was  efficient  when  the  time  of 
exposure  was  five  minutes.  When  the  time  was  reduced  to  two  minutes 
a  negative  result  was  obtained  in  two  out  of  three  guinea-pigs  inocu- 
lated, but  in  one  death  from  tuberculosis  occurred. 

My  experiments  upon  micrococci  are  recorded  in  the  following  table. 

Recent  Cultures  of  Micrococci  in  Flesh-peptone-gelatine. 


Organism. 

Date. 

Temperature  to  which  exposed  ten 
minutes. 

Micrococcus  of  osteomyelitis  .    .  < 
I 

December  8, 
December  20, 
February  8, 

1886. 
1887. 

50°, 
52°, 
54°, 

52  ,  54,  56,  58,  Cont. 
54,  56*,  Cont. 
56*,  58,  Cont. 

Staphylococcus  pyog.  aureus  .  . 

January  11, 

1887. 

54°, 

56*,  58,  60,  Cont. 

Staphylococcus  pyog.  citrous  .    .  i 

January  8, 
January  11, 
January  20, 

1887. 

58°, 
54°, 
56°, 

60*,  62.  64,  Cont. 
56,  58*,  60*. 
58*,  60,  Cont. 

Staphylococcus  pyog.  albus    .    .  j 

December  26, 
January  11, 

1886. 
1887. 

52°, 
54°, 

54,  56*,  Cont. 
56,  58*,  60*. 

Streptococcus  erysipelatus  .    .  . 

December  28, 
January  20, 
January  25, 

1886. 
18S7. 

48°,  50,  52,  Cont. 
50°.  52,  58,  Cont. 
54°,  56,  Cont. 

Micrococcus  tetragenus  .... 

January  25, 

1887. 

54°, 

56*,  58,  Cont. 

Micrococcus  Pasteuri     .    .    .    .  | 

March      29,  18S7. 
April  7, 

50°,  : 

46°, 

2,  54,  56,  58.  Cont- 
48,  50*.  62,  Cont. 

156     STERNBERG,  DEATH-POINT    OF  MICRO-ORGANISMS. 


Fresh  Cultures  of  Sarcina  in  Flesh-peptone-gelatine. 


Organism. 

Date. 

Temperature  to  which  exposed. 

■{ 

December  24,  1886. 
January   11,  1887. 
January  18, 

56°,  58*,  60*,  Cont. 
54°,  56,  58*,  60. 
58°,  60,  Cont. 

r 

.  .  A 

[ 

December  29,  1886. 
January     7,  1887. 
January  11, 
January  18, 

56°,  58*,  60*,  Cont. 
58°,  60*,  62*,  64,  Cont. 
56°,  58,  60*,  Cont. 
60°*,  62,  64,  Cont. 

Gonococcus  of  Neisser. — Believing,  as  I  now  do,  that  this  organism 
is  the  cause  of  the  infectious  virulence  of  gonorrhoeal  secretions  (see 
The  Medical  News  of  Feb.  26,  1887),  I  have  made  the  following  experi- 
ment with  reference  to  its  thermal  death-point.  Some  gonorrhoeal  pus 
from  a  recent  case  which  had  not  undergone  treatment,  was  collected 
for  me  by  my  friend,  Dr.  George  H.  Rohe,  in  the  capillary  tubes  hereto- 
fore described.  A  microscopical  examination  of  stained  cover-glass 
preparations  showed  that  this  pus  contained  numerous  "  gonococci "  in 
the  interior  of  the  cells.  Two  of  the  capillary  tubes  were  placed  in  a 
water  bath  maintained  at  60°  C.  for  ten  minutes.  The  pus  was  then 
forced  out  upon  two  pledgets  of  sterilized  cotton  wet  with  distilled 
water.  Two  healthy  men  had  consented  to  submit  to  the  experiment, 
and  one  of  these  bits  of  cotton  was  introduced  into  the  urethra  of  each 
and  left  in  situ  for  half  an  hour.  As  anticipated,  the  result  was  entirely 
negative.  For  obvious  reasons  no  control  experiment  was  made,  and 
no  attempt  was  made  to  fix  the  thermal  death-point  within  narrower 
limits. 

In  connection  with  these  experiments  upon  the  thermal  death-point  of 
known  pathogenic  organisms,  it  is  of  interest  to  inquire  whether  the 
virulence  of  infectious  material  in  which  it  has  not  yet  been  demon- 
strated that  this  virulence  is  due  to  a  microorganism,  is  destroyed  by  a 
correspondently  low  temperature.  Evidently,  if  this  proves  to  be  the 
case,  it  will  be  a  strong  argument  in  favor  of  the  view  that  we  have  to 
deal  with  a  microorganism  in  these  diseases  also.  We  have  experi- 
mental proof  that  a  large  number  of  pathogenic  organisms  are  killed 
by  exposure  for  ten  minutes  to  a  temperature  of  from  55°  to  60 3  C. 
But,  so  far  as  I  am  aware,  this  low  temperature  would  not  be  likely  to 
destroy  any  of  the  poisonous  chemical  products  which  might  be  supposed 
to  be  the  cause  of  infective  virulence — leaving  aside  the  fact  that  such 
chemical  products  have  no  power  of  self-multiplication,  and,  therefore, 
could  not  be  the  independent  cause  of  an  infectious  disease. 

Vaccine  Virus.— Carstens  and  Coert  have  experimented  upon  the 
temperature  required  to  destroy  the  potency  of  vaccine  virus.  In  a 
paper  read  at  the  meeting  of  the  International  Medical  Congress,  in 
1879,  they  report  as  the  result  of  their  experiments  that  the  maximum 


STERNBERG,  DEATH-POINT   OF   MICRO-ORGANISMS.  157 

degree  of  heat  to  which  fresh  vaccine  can  be  exposed  without  losing  its 
virulence,  probably  varies  between  52°  and  54°  C. 

Rinderpest. — According  to  Semmer  and  Raupach,1  exposure  for  ten 
minutes  to  a  temperature  of  55°  C.  destroys  the  virulence  of  the  infec- 
tious material  in  this  disease. 

Sheep-pox. — The  authors  last  mentioned2  have  also  found  that  the 
same  temperature — 55°  C.  for  ten  minutes — destroys  the  virulence  of 
the  blood  of  an  animal  dead  from  sheep-pox. 

Hydrophobia. — Desiring  to  fix  the  thermal  death-point  of  the  virus 
of  hydrophobia,  I  obtained  through  the  kindness  of  Dr.  H.  C.  Ernst,  a 
rabbit  which  had  been  inoculated,  by  the  method  of  trephining,  with 
material  which  came  originally  from  Pasteur's  laboratory  (see  Dr. 
Ernst's  paper  in  the  April  number  of  this  journal).  The  rabbit  sent 
me  showed  the  first  symptoms  of  paralytic  rabies  on  the  eighth  day  after 
inoculation.  It  died  on  the  eleventh  day  (March  2,  1887),  and  I  at 
once  proceeded  to  make  the  following  experiment : 

A  portion  of  the  medulla  was  removed  and  thoroughly  mixed  with 
sterilized  water,  the  milky  emulsion  was  introduced  into  four  capillary 
tubes,  such  as  had  been  used  in  my  experiments  heretofore  recorded. 
Two  of  these  tubes  were  then  placed  for  ten  minutes  in  a  water  bath, 
the  temperature  of  which  was  maintained  at  60°  C.  Four  rabbits  were 
now  inoculated  by  trephining,  two  with  the  material  exposed  to  60°  C. 
for  ten  minutes,  and  two  with  the  same  material  from  the  capillary 
tubes  not  so  exposed.  The  result  was  as  definite  and  satisfactory  as  pos- 
sible. The  two  control  rabbits  were  taken  sick,  one  on  March  10,  and 
one  on  the  11th;  both  died  with  the  characteristic  symptoms  of  paralytic 
rabies  on  the  third  day.  The  two  rabbits  inoculated  with  material  ex- 
posed to  60°  C.  remained  in  perfect  health.  On  the  26th  of  March  one 
of  these  rabbits  was  again  inoculated  by  trephining  with  material  from 
the  medulla  of  a  rabbit  just  dead  from  hydrophobia.  This  rabbit  died 
from  paralytic  rabies  on  the  8th  of  April.  Its  companion  remains  in 
perfect  health. 

A  second  experiment  was  made  in  the  same  way  on  the  14th  of 
March.  Two  rabbits  were  inoculated  with  material  exposed  for  ten 
minutes  to  a  temperature  of  50°  C. ;  two  with  material  exposed  for  the 
same  time  to  a  temperature  of  55°  C. ;  and  two  control  rabbits  with 
material  not  so  exposed.  One  of  the  rabbits  inoculated  with  materia] 
exposed  to  50°  C.  and  one  of  the  control  rabbits  died  on  the  25th,  the 
other  rabbit  inoculated  with  the  material  exposed  to  50°,  the  other  con- 
trol, and  one  inoculated  with  material  exposed  to  55°,  on  the  26th. 
The  second  rabbit  inoculated  with  material  exposed  to  55°  died  five 
days  later  with  the  characteristic  symptoms  of  the  disease. 

These  experiments  show  then  that  the  virus  of  hydrophobia  is 


1  Deutsche  Zeitschrift  fur  Thier  med.,  vii.  p.  347. 


2  Ibid. 


158     STERNBERG,  DEATH-POINT   OF  MICRO-ORGANISMS. 


destroyed  by  a  temperature  of  60°  C,  and  that  55°  C.  fails  to  destroy 
it — the  time  of  exposure  being  ten  minutes. 

For  convenience  of  reference  the  results  obtained  in  my  own  experi- 
mental studies,  and  those  of  others  referred  to,  are  brought  together  in 
a  single  table.  Where  the  determination  has  not  been  made  by  myself 
the  authority  is  given  in  parentheses  after  the  name  of  the  organism. 
The  time  of  exposure  is  ten  minutes,  unless  otherwise  indicated  by  figures 
in  parentheses  following  those  representing  the  temperature.  The  table 
includes  those  non-pathogenic  organisms  which  have  been  tested  as  well 
as  those  which  are  recognized  as  pathogenic.  In  this  table  I  have 
adopted  the  nomenclature  used  by  Dr.  Fliigge  in  his  recent  work  Die 
Mikrodrganismefb. 


Thermal  Death-point  of  Microorganisms. 


Name  of  Organism. 

Centigrade. 

Fahrenheit 

125.6°  (4m.; 

125.6  (4  m.) 

.  50 

122 

129.2 

132.8 

Bacillus  mallei2  (Loftier)  

.  55 

131 

Bacillus  of  sckweme-rotklauf  (Kouget  of  Pasteur) 

.  58 

136.4 

136.4 

143.6 

,  62 

143.6 

.  56 

132.8 

.  54 

129.2 

Bacillus  pyocyanus  

,  56 

132.8 

136.4 

Bacillus  prodigiosus  

.  58 

136.4 

54 

129.2 

.  54 

129.2 

.  56 

132.5 

.  56 

132  8 

212  (4  m.) 

Bacillus  anthracis  ;  spores  

100 

212  (4  m.) 

Bacillus  butrycus  ;  spores  

.  100 

212  (4  m.) 

100 

212  (4  m.) 

Bacillus  tuberculosis  (Schill  and  Fischer)  . 

.  100 

212  (4  m.) 

.  58 

136.4 

62 

143  6 

62 

143.6 

54 

129.2 

.  58 

136.4 

52 

125.6 

60 

140 

64     •  *  > 

147.2 

G2 

143.6 

54 

129.2 

Rinderpest  virus  (Senimer  and  Raupach)  . 

.  55 

131 

Sheep  pox  virus  (Senimer  and  Raupach)  . 

.  55 

131 

60 

140 

1  Cheese  spirillum.  2  Bacillus  of  glanders.  3  Emmerich's  bacillus. 

4  Brieger's  bacillus.  5  Friedlander's.  .  G  From  water. 

7  Pasteur's  "  microbe  du  cholera  des  poules." 

8  Old  culture  in  flesh-peptone-gelatiue  not  killed  by  60°,  probably  owing  to  the  presence  of  spores. 

9  A  single  experiment.    A  lower  temperature  would  probably  be  effective. 


STERNBERG,  DEATH-POINT   OF  MICRO-ORGANISMS. 


159 


By  reference  to  the  various  tables  giving  the  experimental  data  in 
detail,  it  will  be  seen  that  the  results  are  not  absolutely  uniform  for  the 
same  organism.  Thus,  in  the  experiments  upon  the  typhoid  bacillus  no 
growth  occurred  after  exposure  to  55°  in  one  experiment  (January  15), 
while  in  another  (November  30)  colonies  of  the  typhoid  bacillus  grew 
out  after  exposure  to  this  temperature.  In  this  case  the  thermal  death- 
point  is  placed  at  56°,  no  growth  having  occurred  after  exposure  to  this 
temperature.  Similar  differences,  when  the  temperature  approaches 
that  which  is  uniformly  successful  in  destroying  vitality,  may  be  observed 
with  reference  to  several  of  the  organisms  tested.  But  these  differences 
are  within  comparatively  narrow  limits.  They  are  probably  due  partly 
to  a  difference  in  resisting  power  depending  upon  the  age  of  the  culture, 
and  partly  to  unavoidable  variations  in  the  temperature  during  the 
experiments.  By  very  careful  supervision  and  frequent  stirring  of  the 
water-bath,  variations  in  temperature  have  been  kept  within  narrow 
limits,  but  it  has  been  impossible  to  avoid  them  entirely.  The  same 
thermometer  has  been  used  throughout  (made  by  Schlag  and  Berend, 
Berlin). 

No  attempt  has  been  made  to  fix  the  thermal  death-point  within 
narrower  limits  than  2°  C,  and  in  the  above  table  the  lowest  tempera- 
ture is  given  which  has  been  found,  in  the  experiments  made,  to  destroy 
all  of  the  organisms  in  the  material  subjected  to  the  test.  No  doubt 
more  extended  experiments  would  result,  in  some  instances,  in  a  reduc- 
tion of  the  temperature  given  as  the  thermal  death-point  for  a  degree  or 
more.  But  the  results  as  stated  are  sufficiently  accurate  for  all  practical 
purposes,  and  permit  us  to  draw  some  general  conclusions : 

(a)  The  temperature  required  to  destroy  the  vitality  of  pathogenic 
organisms  varies  for  different  organisms. 

(6)  In  the  absence  of  spores,  the  limits  of  variation  are  about  10° 
Centigrade  (18°  P.). 

(c)  A  temperature  of  566  C.  (132.8°  F.)  is  fatal  to  the  bacillus  of  an- 
thrax, the  bacillus  of  typhoid  fever,  the  bacillus  of  glanders,  the  spiril- 
lum of  Asiatic  cholera,  the  erysipelas  coccus,  to  the  virus  of  vaccinia, 
of  rinderpest,  of  sheep-pox,  and  probably  of  several  other  infectious 
diseases. 

(d)  A  temperature  of  62°  C.  (143.6°  F.)  is  fatal  to  all  of  the  patho- 
genic and  non-pathogenic  organisms  tested,  in  the  absence  of  spores 
(with  the  single  exception  of  sarcina  lutea,  which,  in  one  experiment, 
grew  after  exposure  to  this  temperature). 

(e)  A  temperature  of  100°  C.  (212°  F.)  maintained  for  five  minutes 
destroys  the  spores  of  all  pathogenic  organisms  tested. 

(f)  It  is  probable  that  some  of  the  bacilli  which  are  destroyed  by  a 


160  LOVETT,  MUNRO,  TRACHEOTOMY. 

temperature  of  60°  C.  form  endogenous  spores  which  are  also  destroyed 
at  this  temperature.1 

The  experimental  study,  the  results  of  which  are  recorded  in  the 
present  paper,  was  made,  through  the  courtesy  of  Prof.  Wm.  H.  Welch, 
in  the  pathological  laboratory  of  Johns  Hopkins  University. 


A  CONSIDEEATION  OF 
THE  RESULTS  IN  327  CASES  OF  TRACHEOTOMY, 

PERFORMED   AT   THE   BOSTON    CITY    HOSPITAL   FROM    1864  TO  1887. 

By  Robert  W.  Lovett,  M.D.,  and  John  C.  Munro,  M.D., 

FORMERLY  HOUSE  SURGEONS  AT  THE  HOSPITAL. 

The  operation  of  tracheotomy  was  performed  for  croup  327  times  at 
the  Boston  City  Hospital  from  the  time  of  its  foundation  in  1864  to 
January,  1887.  Up  to  the  year  1880,  only  30  tracheotomies  had  been 
done,  so  that  the  greater  part  of  the  operations  have  been  performed  in 
the  last  six  years.  It  should  be  noted,  in  passing,  that  a  bad  class  of 
cases  would  naturally  come  to  a  city  hospital  for  operation.  In  most 
instances  being  treated  at  home,  medically,  until  an  operation  has 
become  imperative  and  long  after  it  has  become  advisable,  they  are 
brought  hurriedly  for  operation  often  in  a  hopelessly  bad  condition.  If 
the  parents  wish  or  if  an  operation  seems  likely  to  afford  even  temporary 
relief  to  the  patient,  tracheotomy  is  performed,  and  thus  many  hopeless 
cases  are  yearly  operated  upon ;  all  of  which  are  included  in  the 
analysis.  We  are  indebted  to  the  visiting  surgeons  of  the  hospital  for 
permission  to  publish  the  following  cases. 

Of  the  327  cases,  232  died  and  95  (29.05  per  cent.)  recovered.  The 
causes  of  death  were,  septicaemia  in  62  cases,  extension  of  the  diphtheritic 
process  to  the  trachea  and  bronchi  (doubtless  including  many  pneumonia 
cases)  in  101  cases,  exhaustion  in  12  cases,  death  on  the  table  in  10 
cases,  heart  failure  in  6  cases,  various  causes  (pneumonia,  peritonitis, 
scarlet  fever,  nephritis,  embolism,  marasmus)  in  6  cases,  undetermined  in 
35  cases. 

Autopsies  were  so  few  that  a  clinical  estimate  of  the  cause  of  death 
had  to  serve  in  most  cases ;.  such  a  classification  is  approximate  at  best 
and  the  distinctions  were  by  no  means  always  clear.  When  death  was 
preceded  by  gradually  increasing  dyspnoea  it  was  considered  that  exten- 


1  This  question  demands  further  experimental  investigation. 


LOVETT,  MUNROj  TEACHEOTOMY. 


161 


sion  of  the  diphtheritic  process  to  the  bronchi  was  the  cause  of  death 
and  the  truth  of  this  was  often  proved  by  autopsy.  In  other  cases  pro- 
found septic  poisoning  was  evident  as  the  chief  cause  of  death.  These 
are  the  two  great  classes  into  which  the  majority  of  cases  fall,  other 
causes  of  death  seeming  incidental.  Children  with  septicemic  symptoms 
died  more  quickly  after  operation  than  those  dying  by  extension  of  the 
process  to  the  bronchi.  An  average  of  the  two  classes  showed  that 
septicemic  patients  died  on  the  average  two  days  after  operation,  while 
children  dying  by  extension  lived  three  days. 

The  relation  of  the  number  of  deaths  from  extension  to  those  from 
septicaemia  is  shown  below. 

Extension.  Septicemia. 

In  all  the  fatal  cases  .       .       .       .  -If      to  1 

In  children  under  2  years  3  J       to  1 

In  children  from  2  to  10  years   ....    1^      to  1 

It  can  be  seen  from  this  that  young  children  are  particularly  liable  to 
that  distressing  cause  of  death,  extension  of  the  process  to  the  bronchi. 
When  this  happens  there  is  no  euthanasia,  death  is  the  slowest  and  most 
painful  of  suffocations,  and  only  when  septicaemia  to  the  point  of  stupe- 
faction is  present  at  the  same  time  does  the  child  escape  a  horrible 
amount  of  suffering.  The  frequency  of  this  painful  ending  then  is  not 
to  be  lost  sight  of  in  recommending  the  operation  as  a  means  of  euthanasia, 
especially  in  children  under  two  years  of  age. 

10  cases  died  on  the  table.  2  of  these  evidently  died  of  heart  failure, 
for  they  stopped  breathing  before  the  trachea  was  opened  and  had  but 
slight  hemorrhage.  4  had  profuse  hemorrhage,  and  2  died  of  shock 
some  little  time  after  the  tube  was  put  in  place  and  everything  seemed 
favorable.  In  the  remaining  2  cases  the  records  are  not  full.  The  6 
cases  classed  as  heart  failure  did  not  die  on  the  table,  but  from  the  first 
to  the  fifth  day  after  operation. 

An  attempt  was  made  to  find  the  ultimate  result  in  the  95  patients 
that  recovered.  23  cases  recovered  in  1886,  and  were  considered  as  too 
recent  to  be  of  value. 

Of  the  72  that  recovered  previous  to  January,  1886,  56  have  been 
personally  investigated,  while  16  could  not  be  found.  The  research  was 
made  especially  dilficult  by  the  fact  that  it  was  so  common  for  the 
parents  to  move  after  an  attack  of  diphtheria  and  the  consequent  investi- 
gation by  the  Board  of  Health.  Of  the  72  families,  57  had  moved  at 
least  once.  15  cases  were  seen  from  one  to  two  years  after  operation  ; 
16  cases  in  three  years ;  12  cases  in  four  years;  2  cases  in  five  years  ; 
6  cases  in  six  years ;  4  cases  in  seven  years ;  1  case  in  twenty-one  years. 
26  have  never  been  ill  in  any  way  since  recovery  from  the  operation. 

NO.  CLXXXVII.— JULY,  1887.  11 


162 


LOVETT,  MUKRO,  TRACHEOTOMY. 


7  have  had  pneumonia,  measles,  or  mumps,  but  have  fully  recovered, 
no  one  of  them  having  had  croup  at  the  time  of  illness.  2  have  had 
diphtheria  a  second  time  without  laryngeal  complication ;  1,  nine  years 
old,  two  years  after  operation,  and  1,  twenty  years  old,  four  years  after. 

With  eight  exceptions,  the  patients  have  been  free  from  any  attack  of 
croup  since  operation.  One,  five  years  old,  operated  on  in  1885,  has  had 
two  attacks,  one  of  which  Avas  quite  severe.  One,  ten  years  old,  operated 
on  in  1884,  has  had  one  or  two  attacks,  and  is  in  poor  general  condition. 
One,  four  years  old,  operated  on  in  1885,  is  apt  to  be  croupy  with  a  slight 
cold.  One,  six  years  old,  operated  on  in  1885,  the  same.  One,  fourteen 
years  old,  operated  on  in  1883,  the  same.  One,  ten  years  old,  operated 
on  in  1885,  has  croupy  cough.  One,  seven  years  old,  operated  on  in 
1884,  was  liable  to  be  croupy  for  a  while  after  operation,  but  is  not  so 
now.    One,  eleven  years  old,  operated  on  in  1883,  the  same. 

Of  complications  coming  after  operation,  one  had  nephritis  and  paral- 
ysis, but  recovered ;  one  had  nephritis  for  four  months.  One  had 
"abscesses."  One,  a  boy  ten  years  old,  operated  on  in  1881,  could  not 
blow  his  nose  for  two  years,  but  is  well  now. 

There  have  been  no  deaths  in  the  56  cases  investigated,  and  there  is 
no  reason  to  believe  that  these  are  any  more  favorable  than  the  16  that 
could  not  be  found. 

As  to  present  condition,  53  may  be  said  to  be  in  good  general  health : 
10  to  15  are  said  to  take  cold  more  easily  than  before.  That  it  is  not 
a  very  serious  matter  may  be  seen  by  the  fact  that  only  6  are  said  to  be 
liable  to  sore  throats,  of  whom  2  have  tonsillitis  at  times,  and  the  re- 
mainder are  liable  to  have  sore  throats  when  they  catch  cold.  Of  the  3 
who  w7ere  found  not  to  be  in  good  condition,  one,  six  years  old,  operated 
on  a  year  and  a  half  ago,  has  phthisis,  but  no  laryngeal  symptoms. 
The  second,  noted  above,  is  in  bad  general  condition,  hoarse,  and  croupy. 
The  third  is  a  delicate  boy,  five  years  old,  with  no  positive  signs  of 
trouble  except  a  tendency  to  croup  and  illness. 

The  voice  is  clear  in  all  but  4  cases  ;  in  one  of  the  latter,  a  girl  of 
thirteen,  operated  on  two  years  ago,  the  voice  is  not  so  clear  as  before 
operation,  and  she  cannot  sing  so  high  as  before.  The  second,  four 
years  old,  has  a  fairly  clear  voice,  but  it  is  said  to  be  less  so  than  before 
operation,  two  years  ago  ;  two  are  said  to  be  hoarse  when  they  have  slight 
colds.  The  scars  in  all  cases  are  healed  and  are  more  or  less  conspicuous 
according  to  the  severity  of  the  original  wound ;  none  were  found  adhe- 
rent, and  in  no  instance  had  the  scar  travelled  downward  toward  the 
sternum  as  mentioned  by  Neukomm.1  In  nearly  all  the  cases  a  linear 
depression  in  the  trachea  admitting  the  edge  of  the  finger-nail  could  be 


1  Neukomm:  Centralb.  f.  Chirurg.,  1885,  No.  38. 


LOVETT,  MUNBO,  TRACHEOTOMY. 


163 


felt  at  the  site  of  the  original  wound,  but  in  one  case  operated  on  in 
1880,  by  the  low  operation,  no  nick  was  felt  in  the  trachea. 

There  were  4  cases  of  stenosis  which  are  noted  later  in  the  article. 

It  has  been  stated  that1  the  operation  tends  to  become  less  fatal  in 
any  place  as  the  years  go  by.  In  Berlin2  the  death-rate  after  operation 
fell  22  per  cent,  in  six  years,  and  in  Paris,3  at  the  Hopital  des  Enfants 
Malades,  it  fell  nearly  30  per  cent,  in  six  years. 

In  11,696  cases  reported  by  Agnew,4in  1878,  the  recovery  per  cent, 
was  26.25.  In  1137  cases  reported  since  then  which  were  grouped 
merely  for  comparison  on  this  point,  the  recovery  rate  was  33.8  per  cent. 
But  in  the  present  series  of  cases  no  such  result  was  noted.  From  1881  to 
1885  the  recovery  per  cent,  fell  from  35  to  26 ;  in  1886  it  rose  again  to 
29,  but  the  general  tendency  has  been  downward,  a  fact  which  is  proba- 
bly dependent  on  the  extension  of  the  operation  to  more  and  more 
hopeless  cases  each  year.  Moreover,  Wanscher,5  iu  Copenhagen,  in 
several  years  noted  no  such  falling  off  in  the  fatality  per  cent.  Statistics 
definite  enough  to  clear  up  the  point  are  too  few. 

It  became  apparent  while  studying  the  cases  that  there  was  a  marked 
variation  in  the  proportion  of  recoveries  at  the  different  seasons  of  the 
year.  Therefore,  a  calculation  was  made  of  the  average  monthly  mor- 
tality per  cent,  in  each  of  the  twelve  months  for  five  years  preceding 
1886,  and  the  result  is  shown  graphically  in  Table  I.  It  will  be  seen 
that  in  the  winter  months  the  smallest  proportion  of  cases  recover,  not 
20  per  cent,  in  December,  February,  and  March,  while  from  the  latter 
month  the  recovery  rate  rises  until  July,  when  about  60  per  cent,  of  all 
cases  operated  on  get  well.  In  a  general  way,  each  year  showed  the 
same  tendency  when  considered  by  itself.  As  a  matter  of  interest,  the 
per  cent,  of  mortality  from  diphtheria  in  the  city  at  large  was  calculated 
by  the  month  for  the  same  five  years  from  the  tables  of  the  Board  of 
Health,6  and  a  very  striking  correspondence  was  noticed.  The  diph- 
theria mortality  per  cent,  curve  is  shown  in  Table  IV. 

To  see  if  the  tracheotomy  mortality  per  cent,  bore  a -similar  relation 
to  other  zymotic  diseases  than  diphtheria,  the  monthly  mortality  per 
cent,  of  scarlet  fever  (chosen  only  as  a  representative)  for  the  same  five 
years  was  calculated  for  the  whole  city,  and  the  result  is  shown  in 
Table  VII. 

By  comparison  of  these  three  tables  it  will  be  seen  that  from  1881  to 
1885  inclusive,  the  tracheotomy  death-rate  at  the  Boston  City  Hospital 

1  Hugonnai :  Das  erste  100  Croup  Operationen  in  Zurich.    Iuaug.  Diss.,  Zurich,  1878. 

2  Kronlein :  Archiv  f.  klin.  Ohir.,  Bd.  xxi.  Heft  2. 

3  Bourdillat :  Bull.et  Soc.  M6d.  Hop.  Paris,  1867,  39. 

4  Agnew ;  System  of  Surgery,  vol.  iii. 

6  Wanscher :  Om  Diphtheritis  og  Croup  saerlight  med.  Hyensyen  til  Tracheotomieu  ved  SAHUM  for 
Doctor  graded  i  Medicinen.    Kjoebenhavn,  1S77. 
6  Reports  of  the  Boston  Board  of  Health,  1881-85. 


164 


LOVETT,  MUNEO,  TRACHEOTOMY. 


varied  by  the  month  in  the  closest  correspondence  to  the  mortality  per 
cent,  of  diphtheria  for  the  same  time  in  the  whole  city  of  Boston,  and 
that  it  did  not  vary  at  all  in  correspondence  with  the  death-rate  from 
scarlet  fever  in  the  whole  city.  Nor  does  it  correspond  to  the  general 
monthly  mortality  of  the  city  for  all  diseases  during  the  same  five  years. 
In  a  word,  when  diphtheria  is  most  fatal  in  the  city,  tracheotomy  is  most 
fatal  at  the  hospital.  That  this  variation  is  not  due  to  the  greater  pre- 
valence of  scarlet  fever  or  diphtheria  at  different  seasons  is  shown  by 
Tables  II.  and  V.,  which  show  the  monthly  number  of  cases  reported 
for  the  five  years  of  each  disease.  It  is  also  of  much  interest  to  see  how 
closely  the  number  of  deaths  from  croup  and  diphtheria  in  the  whole 
city  correspond  when  considered  by  the  month  in  the  same  way.  (Table 
III.)  The  same  correspondence  was  noted  for  1876-77  by  Dr.  F.  W. 
Draper.1 

It  does  not  come  within  the  scope  of  this  paper  to  enter  upon  any  dis- 
cussion as  to  the  identity  of  croup  and  diphtheria ;  at  the  same  time  it 
is  easy  to  see  that  the  correspondences  and  variations  noted  above  lend  a 
very  strong  weight  to  the  assertion  that  croup  and  diphtheria  are  one 
and  the  same  disease.  However  it  may  be  in  other  places,  idiopathic, 
non-diphtheritic  croup  is  very  rare  in  Boston ;  whether  it  exists  at  all 
is  questioned  by  many.  The  overwhelming  majority  of  all  cases  coming 
for  operation  to  the  hospital  present  some  signs  of  diphtheritic  infection, 
membrane  in  the  throat  or  nose,  enlarged  glands  in  the  neck,  albumin- 
uria, septicaemia,  and  the  like. 

If  the  seasonal  death-rate  from  diphtheria  in  a  city  affects  the  trache- 
otomy death-rate  so  much  as  our  tables  would  seem  to  show,  we  should 
expect  that  in  cities  where  a  low  death-rate  from  diphtheria  prevails 
unusually  favorable  results  would  follow  tracheotomy.  And  this  may 
account  for  the  otherwise  inexplicable  figures  given  by  Wanscher,  of 
Copenhagen,  where  of  400  cases  operated  on  in  hospital  practice  42  per 
cent,  recovered.    The  table  shows  the  rest. 

To  the  1000  of  the 
living  population. 

General  death-rate  in  Copenhagen,  1880-1885  .  .  .  22.8 
General  death-rate  in  Boston,  1880-1885  ....  22.5 
Diphtheria  death-rate  in  Copenhagen,  1880-1885  .  .  0.25 
Diphtheria  death-rate  in  Boston,  1880-1885      .       .       .  1.35 

Unfortunately,  statistics  are  not  to  be  obtained  for  similar  investiga- 
tion in  other  cities. 

The  presence  of  membrane  in  the  pharynx  is  by  no  means  an  invari- 
able accompaniment  of  the  laryngeal  trouble,  for  it  was  noted  as  having 
been  present  in  the  pharynx  in  158  cases  and  absent  in  93,  while  in  76 
there  was  no  definite  note.    It  was  undoubtedly  seen  but  not  noted  in 

1  Reports  of  Boston  Board  of  Health,  1877-78. 


LOVETT,  MUNRO,  TRACHEOTOMY. 


165 


many  cases,  whereas  nearly  every  case  in  which  it  was  absent  was  prob- 
ably entered  in  the  notes,  so  that  the  figures  given  above  by  no  means 
represent  the  true  proportion.  But  the  interest  of  the  two  classes  of 
cases  lies  in  the  difference  of  their  death-rates.  Of  the  158  cases  where 
membrane  was  present  in  the  pharynx  at  the  time  of  operation  44  or  28 
per  cent,  recovered,  in  the  93  cases  where  membrane  was  absent  from  the 
pharynx  37.6  per  cent,  recovered.1  That  this  difference  in  the  per  cent, 
is  not  due  to  the  fact  that  the  cases  where  membrane  was  absent  were 
older  children,  is  shown  by  the  average  age  of  the  two  classes : 

Where  membrane  was  present  the  average  age  of  the  158  cases  was 
4.4  years. 

Where  membrane  was  absent  the  average  age  of  the  93  cases  was  4.1 
years.  * 

That  is,  in  spite  of  the  fact  that  the  children  were  younger,  10  per 
cent,  more  recovered  where  membrane  was  not  present  in  the  pharynx 
at  the  time  of  operation. 

In  the  majority  of  cases  the  attack  of  croup  had  been  preceded  by  ill- 
ness varying  from  one  to  seven  days  in  duration.  Oftenest  there  was 
the  history  of  an  attack  of  pharyngeal  diphtheria  preceding,  but  some- 
times there  had  only  been  a  day  or  so  of  general  malaise  without  definite 
throat  symptoms.  In  an  average  of  225  cases  the  attack  of  croup  came 
on  the  fifth  day  of  the  illness,  and  in  only  10  cases  was  the  croup  not 
preceded  by  at  least  one  day's  illness. 

Perhaps  the  most  important  question  of  all  is  the  influence  of  early  or 
late  operation  as  it  affects  recovery,  as  it  is  one  of  the  very  few  condi- 
tions under  the  control  of  the  surgeon.  The  table  shows  the  recovery- 
rate  in  cases  operated  upon  within  one,  two,  three,  and  four  days  after 
the  beginning  of  the  obstructed  respiration. 


Day  of  operation. 

Number  of  cases 

Recovery. 

Per  cent,  of  recover 

1 

-  123 

40 

32.5 

2 

86 

24 

28.0 

3 

33 

8 

25.3 

4 

7 

1 

14.0 

In  the  same  line  of  argument  the  amount  of  the  patient's  dyspnoea  at 
the  time  of  operation  serves  to  advocate  the  performance  of  tracheotomy 
while  the  dyspnoea  is  yet  moderate.  In  154  cases  the  dyspnoea  before 
operation  was  noted  as  "severe;"  of  these,  21  per  cent,  recovered.  In 
124  where  it  was  noted  as  "  moderate,"  35  per  cent,  recovered.  The 
argument  against  early  operation  is  of  course  the  possibility  of  a  patient's 
recovery  from  even  severe  dyspnoea  without  tracheotomy ;  on  this  point 

1  Honsell :  Aerztl.  Mittheil.  aus  Baden,  xxxvi.,  l>v_>. 


166 


LOVETT,  MUNEO,  TRACHEOTOMY. 


authorities  differ  very  widely.  Steiner1  has  seen  only  three  recoveries 
of  this  sort.  Mackenzie2  sets  the  death-rate  without  operation  at  90  per 
cent.,  and  in  33  cases  of  croup  treated  medically  many  years  ago  by  Dr. 
John  Ware,3  30  died.  On  the  other  hand  are  arrayed  Lewis  Smith,4 
Meigs  and  Pepper,5  and  Agnew,6  who  believe  that  recovery  without 
operation  is  more  frequent  than  has  commonly  been  supposed.  The 
experience  at  the  City  Hospital  has  been  as  follows :  forty  cases  of 
diphtheritic  croup  have  been  treated  medically  and  every  one  died. 
Dr.  G.  W.  Gay,  visiting  surgeon,  wrote  in  1885,7  "  Not  a  single  case  of 
pseudo-membranous  laryngitis  has  ever  recovered  in  this  hospital  with- 
out operation."  And  he  quoted  Dr.  D.  W.  Cheever,  senior  visiting 
surgeon,  as  writing  to  him  in  1884,8  "After  reflection  I  cannot  recall  a 
case  of  membranous  laryngitis  that  I  have  known  to  recover  without 
tracheotomy."  Since  Dr.  Gay's  article  was  written  there  have  been  two 
recoveries  from  moderate  dyspnoea  without  operation. 

The  age  of  the  patient  is,  of  course,  an  important  consideration,  the 
mortality-rate  falls  as  the  age  increases,  up  to  eight  or  ten  years.  In 
1600  cases  collected  from  Cohen,9  Schuller,10  Birnbaum,11  Mastin,12  etc., 
and  tabulated  with  regard  to  the  age  of  the  patients,  the  recovery-rate 
in  children  less  than  two  years  old  was  20  per  cent.,  rising  steadily  until 
the  age  of  eight  years  was  reached,  when  it  was  40  per  cent.  The  327 
cases  reported  here  followed  much  the  same  course,  except  in  the  youngest 
children,  where  the  operation  proved  much  more  fatal.  Of  42  patients 
under  two  years  of  age  only  3  recovered,  1  eleven  months  old,  and  2 
fifteen  months  old,  all  nursing  children.  The  oldest  case  to  recover  was 
a  girl  sixteen  years  old,  and  several  adults  died. 

There  are  several  minor  symptoms  that  deserve  mention.  Nasal  dis- 
charge was  almost  always  present  and  had  no  special  significance. 
When  it  was  associated  with  severe  septicaemia  it  was  ordinarily  foul- 
smelling.  Cervical  glandular  swelling,  in  the  same  way,  was  generally 
present,  being  noted  as  absent  in  only  24  cases.  It  was  present  in  all 
sorts  of  cases,  and  its  only  significance  was  that  when  it  gradually  in- 
creased after  operation,  death  from  septicaemia  followed  in  an  overwhelm- 
ing majority  of  cases.  To  be  sure,  two  or  three  cases  got  well  after 
having  developed  an  amount  of  glandular  swelling  that  made  the  neck 

1  Steiner,  quoted  by  Gay:  Wood's  Ref.  Handbook  of  Med.  Sci ,  vol.  ii.  p.  344. 

2  Mackenzie  :  Diseases  of  the  Throat  and  Nose.  3  Ware,  quoted  by  Gay,  Ibid. 

4  Lewis  Smith :  Dis.  of  Children,  Phila.,  1881 ;  also  Amer.  Journ.  of  Med.  Sci.,  April,  1885,  p.  319. 

5  Meigs  and  Pepper  :  Diseases  of  Children.  6  Agnew,  loc.  cit. 

7  Gay  :  Wood's  Ref.  Handbook  of  Med.  Sci.,  vol.  ii.  p.  344. 

8  Gay  :  Phila.  Med.  News,  July  12,  1884. 

9  Cohen  :  Croup  in  its  Relation  to  Tracheotomy,  1884. 
i°  Schuller  :  Deutsche  Chir.,  Lief  37,  Stuttgart. 

H  Birnbaum  :  Arch,  f  klin.  Chir.,  xxxi.  p.  333. 
12  Mastin  :  Gaillard's  Med.  Journ.,  xxix.  1  p.  1. 


LOVETT,  MUNRO,  TRACHEOTOMY. 


167 


double  its  ordinary  size,  but  in  general  when  the  neck  tape  had  to  be 
loosened,  after  it  was  once  tied  in  place,  it  meant  death  for  the  patient. 

Albumen  was  present  in  the  urine  of  five-sixths  of  all  the  cases  in  which 
an  examination  was  made  and  recorded  (75  in  number).  It  appeared 
in  all  classes  of  cases  and  was  particularly  abundant  in  bad  cases  of 
septicaemia.  Sugar  was  temporarily  present  in  the  urine  of  one  child  who 
recovered. 

The  discharge  from  the  trachea  tube  after  operation  furnished  perhaps 
the  most  important  indication  of  a  patient's  progress.  The  discharge 
was  classified  as  loose  and  as  gummy,  and  the  line  between  the  two 
classes  was  easy  enough  to  draw  ordinarily.  The  inner  tube  was  always 
taken  out  and  cleaned  every  two  or  three  hours,  and  at  these  times  the 
character  of  the  discharge  taken  from  it  was  noted.  Sometimes  there 
was  no  discharge  at  all,  and  then  the  case  was  classed  as  "  discharge  sup- 
pressed ;"  when  it  was  gummy  it  was  always  scant.  The  importance  of 
the  tube  discharge  with  reference  to  the  prognosis  of  the  cases  is  shown 
in  the  following  table : 

Number  of  Number  of 

Cases.       Kecoveries.  Per  cent. 

When  the  discharge  was  loose  through- 
out   .      .    83         53  60 

When  the  discharge  was  gummy  at  any 
time,  even  temporarily     ...       86         11  13 

When  the  discharge  was  suppressed    .15  0  0 

The  notes  wrere  indefinite  in  the  other  143. 

The  appearance  of  blood  in  the  tube  discharge  was  a  matter  of  no 
significance.  It  was  always  present  for  a  while  after  operation  and  re- 
appeared in  all  classes  of  cases  at  irregular  intervals,  sometimes  as  late 
as  the  fifth  day  after  operation. 

The  temperature  possessed  no  more  than  its  usual  significance  in  acute 
febrile  diseases ;  when  it  rose  higher  than  105°  at  any  time  the  child 
rarely  recovered.  The  temperature  generally  rose  several  degrees  after 
operation,  but  it  was  of  no  significance  unless,  as  pointed  out  by  Ripley,1 
it  remained  high,  when  it  could  be  inferred  that  the  disease  was  progress- 
ing unfavorably.  But  a  marked  rise  on  the  third,  fourth,  or  fifth  day 
after  operation  was  the  most  ominous  sign  and  generally  ushered  in  a 
fatal  result.  In  the  majority  of  cases  the  temperature  ranged  between 
99°  and  103°. 

The  treatment  in  all  these  years  has,  of  course,  varied  very  much. 
Of  late  years  the  steam  pipes  in  the  tracheotomy  rooms  have  been 
tapped,  and  for  several  days  after  operation  every  child  lies  in  a  cloud 
of  steam  coming  from  these  pipes.  In  former  years  a  hand  atomizer 
was  used.    Free  stimulation  and  milk  ad  libitum  form  the  treatment  of 

i  Kipley  :  Med.  Record,  Jan.  24,  1885. 


168 


LOVETT,  MUNRO,  TEACHEOTOMY. 


nearly  all  cases  after  operation.  66  cases  were  treated  with  mer- 
cury in  small  and  frequent  doses  (-g1^  of  a  grain  of  corrosive  subli- 
mate or  \  of  a  grain  of  calomel  every  two  hours),  and  the  recovery  per 
cent,  was  28,  and  did  not  differ  materially  from  the  recovery  per  cent, 
of  156  cases  which  were  treated  by  steam,  brandy,  and  milk,  where  40 
cases,  or  25  per  cent.,  got  well.  Quinine  was  given  through  the  course 
of  the  disease  in  53  cases,  and  the  recovery  per  cent,  here  was  39,  much 
larger  than  in  the  other  cases  mentioned  above,  but  the  numbers  are 
altogether  too  small  to  warrant  any  conclusions  as  to  the  comparative 
efficacy  of  different  methods  of  treatment. 

In  turn,  ipecac,  lime-water  spray,  chlorate  of  potash,  iron,  pilocarpine, 
pepsine,  etc.,  have  held  the  chief  place,  but  the  number  of  cases  in  which 
each  has  figured  is  too  small  to  be  worth  analyzing,  and  iron,  quinine, 
and  mercury  hold  the  chief  places.  In  connection  with  the  mercurial 
treatment,  it  should  be  mentioned  that  an  excessive  flow  of  saliva  is 
an  occasional  accompaniment  of  laryngeal  diphtheria.  This  was  noted 
in  several  cases  in  which  mercury  was  not  used  at  all,  and  for  that 
reason  the  drug  is  probably  credited  with  much  salivation  for  which 
it  is  not  accountable.  In  the  same  way  diarrhoea,  many  times  noted 
after  the  continued  use  of  calomel  in  ^  grain  doses,  often  came  on 
where  no  mercurial  had  been  administered.  Young  children  took  -fa 
of  a  grain  of  corrosive  sublimate  for  two  or  three  days,  and  within 
that  limit  they  were  rarely  salivated,  and  still  more  rarely  did  they 
have  diarrhoea.  If  it  was  continued  longer,  or  if  it  was  given  in 
larger  doses,  it  was  apt  to  cause  one  or  both.  Calomel,  on  the  other 
hand,  was  likely  to  cause  diarrhoea,  if  used  even  moderately. 

When  a  patient  progressed  well,  on  the  fifth,  sixth,  or  seventh  day 
the  neck  tape  was  cut,  and  the  tube  was  taken  out  quietly,  without 
any  preliminary  testing  of  the  larynx  by  stopping  the  tube.  In  65 
cases  of  the  95  which  recovered,  the  tube  was  finally  removed  by  the 
eighth  day  (once  on  the  third  day,  and  twice  on  the  fourth),  and  was 
not  replaced.  In  9  cases  it  was  necessary  to  put  back  the  tube  within 
a  few  hours  of  its  first  removal,  and  to  leave  it  for  a  few  days  more, 
on  account  of  the  difficulty  which  the  child  experienced  in  breathing 
without  the  tube.  In  4  others  it  had  to  be  replaced  a  second  time, 
but  it  was  not  worn  more  than  a  month  altogether  in  any  one  of 
them,  while  in  4  others  it  was  impossible  to  remove  the  tube  defi- 
nitely for  periods  varying  from  3  months  to  3  years.  These  four  cases 
have  been  reported  elsewhere.1  This  difficulty  in  getting  the  children 
to  breathe  without  their  tubes  at  the  usual  time  for  so  doing  did  not 
seem  to  be  due  to  any  unusually  early  or  late  time  of  the  first  attempt 
at  removal.    In  most  of  them,  as  in  the  others,  the  attempt  at  removal 


1  Lovett :  Boston  Med.  and  Surg.  Journal,  July  22,  1886. 


LOVETT,   MUNEO,  TRACHEOTOMY. 


169 


was  made  on  the  fifth,  sixth,  or  seventh  day,  and  not  until  the 
dyspnoea  began  (usually  some  hours  after  the  tube  was  taken  out) 
was  there  any  indication  that  matters  were  to  go  wrong.  These  were 
average  cases  in  every  other  way. 

Diphtheria  of  the  wound  was  noted  in  only  6  cases  in  the  327  ; 
3  of  these  recovered.  In  2  other  cases  diphtheritic  membrane  appeared, 
once  on  the  ear,  and  once  on  the  lip. 

17  times  the  tracheotomy  was  done  for  croup  (mostly  diphtheritic 
in  type)  occurring  during  the  course  of  the  exanthemata,  mumps,  or 
whooping- cough.  In  10  cases  it  was  a  complication  of  measles,  and 
of  these  cases  5  recovered.  A  very  unusual  state  of  affairs,  if  we  may 
believe  Cohen,1  who  says,  "  Croup  supervening  on  the  exanthemata  is 
not,  as  a  rule,  amenable  to  tracheotomy,"  and  Settegast2  says  "  Cases  of 
recovery  are  so  rare  as  'to  be  mentioned  individually."  The  other  7 
cases  after  mumps,  scarlet  fever,  and  whooping-cough  were  all  fatal. 

The  amount  of  nourishment  taken  by  a  patient  indicated,  of  course, 
in  a  general  way  the  progress  of  the  case.  The  children  were  encour- 
aged to  take  as  much  milk  as  possible,  and  in  many  cases  were  fed 
every  hour.  They  took  from  20  to  40  ounces  of  milk  a  day,  30 
was  a  fair  amount,  and  when  a  child  took  less  than  25  it  rarely 
recovered.  Milk  came  out  through  the  tube  and  wound  in  some  cases, 
but  it  was  no  very  serious  matter,  for  in  7  cases  when  it  was  noted,  5 
recovered.  There  were  many  curious  complications  in  all  these  cases, 
but  those  of  practical  interest  have  already  been  mentioned. 

The  results  of  operation  in  this  series  of  cases  are  above  the  average,  in 
spite  of  the  predominance  of  bad  cases.  They  show  that  young  children 
are  especially  liable  to  have  extension  of  the  diphtheritic  process  to  the 
bronchi  and  lungs ;  in  fact,  that  the  chances  are  three  to  one  that  if  they 
die  they  will  die  of  suffocation.  That,  in  Boston,  tracheotomy  at  the 
hospital  is  most  fatal  at  those  times  when  diphtheria  is  most  fatal  in  the 
whole  city,  and  incidentally  that  the  mortality  per  cent,  from  croup  and 
diphtheria  in  the  whole  city  vary  by  the  month  in  unison.  That  cases 
with  membrane  in  the  pharynx  at  the  time  of  operation  are  more  likely 
to  die  than  those  where  it  is  not  present.  That  the  mortality  per  cent, 
after  tracheotomy  rises  steadily  as  the  operation  is  done  on  the  first, 
second,  third,  or  fourth  day  of  the  difficult  breathing.  That  nasal  dis- 
charge, albuminuria,  and  enlargement  of  the  cervical  glands,  are 
symptoms  of  less  moment  than  the  character  of  the  discharge  from  the 
trachea  tube,  which  is  the  most  important  index  of  the  progress  of  ;i 
case,  and  that  the  recovery-rate  varies  nearly  50  per  cent,  between  cases 

1  Cohen  ;  Croup  in  its  Relation  to  Tracheotomy.  1874. 

2  Settegast :  Archiv  fur  klin.  Cliir.,  xxiii.  270. 


170 


LOVETT,  MUNRO,  TRACHEOTOMY. 


where  the  discharge  is  loose  throughout  and  those  where  it  is  gummy  at 
any  time. 

For  purposes  of  comparison,  a  table  of  all  available  reported  cases  of 
tracheotomy  has  been  constructed.  As  a  rule,  no  group  of  less  than  five 
operations  has  been  considered,  very  few  contain  less  than  ten,  for  the 
reason  that  recoveries  predominate  enormously  in  the  very  small  groups. 
The  journals  are  full  of  accounts  of  two  or  three  successful  cases  reported 
by  practitioners  who  may  or  may  not  hint  at  various  failures  in  the  past. 
It  was  considered  that  to  count  such  groups  would  be  misleading,  and 
they  were  all  rejected,  whether  favorable  or  not,  because  they  were  not 
considered  representative.  The  cases  are  arranged  by  countries,  and, 
so  far  as  it  has  been  possible  to  tell,  no  cases  have  been  reported  more 
than  once. 


Total. 

Recovered. 

Died. 

Per  cent. 
Recovered. 

German  authors  

5795 

1851 

3944 

31 

German  hospitals  

3063 

939 

2124 

30 

British  authors  

433 

138 

295 

31 

French  authors   

92421 

2242 

6834 

24 

Various  countries  

1993 

657 

1336 

32 

American  authors  

1327 

308 

1019 

23 

21,853 

6135 

15,552 

28 

1  166  not  healed. 


REVIEWS. 


The  Science  and  Art  of  Obstetrics.  By  Theophilus  Parvix,  M.D., 
LL.D.,  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the 
Jefferson  Medical  College,  Philadelphia,  and  one  of  the  Obstetricians  to  the 
Philadelphia  Hospital.  Illustrated  with  two  hundred  and  fourteen  woodcuts 
and  a  colored  plate.   Pp.  xv.  701.    Philadelphia :  Lea  Brothers  &  Co.,  1886. 

There  is  always  room  for  a  good  book.  The  more  thoroughly  beaten 
are  the  paths,  the  more  familiar  each  commanding  feature  of  the  land- 
scape, the  better  welcome  to  one  that  can  picture  anew  the  familiar 
scene,  and  throw  upon  it  broader  lights  or  bolder  contrasts.  But  where 
so  many  know,  and  so  many  have  described  it,  all  the  more  difficult  for 
one  to  enter  upon  the  field.  He  must  expect  criticism.  No  two  see 
the  same  well-known  object  from  the  same  point  of  view.  The  perspec- 
tive angles  are  all  different.  In  the  great  field  of  gynecic  literature 
obstetrics  seems  to  stand  still.  It  is  not  still,  however.  It  has  the 
advance  that  is  made  all  along  the  line,  and  has  seemed  to  move  less 
rapidly  in  contrast  to  the  brilliant  progress  of  gyniatrics. 

There  is  enough  of  the  new  to  signalize  the  advent  of  a  new  book  in 
obstetrics,  and  it  is  a  graceful  act  in  Dr.  Parvin  to  mark  his  translation 
from  his  old  field  of  work  in  the  West  to  one  of  broader,  more  ardent 
labor  in  the  East  by  an  elaborate  treatise  upon  a  subject  that  he  has 
made  his  own,  and  won  an  honorable  fame. 

His  task  has  been  a  difficult  one,  and  to  which  he  must  have  been 
impelled  by  a  higher  motive  than  ambition.  We  needed  the  book,  not 
in  the  sense  of  lack  of  quantity  before  the  medical  public  from  which 
to  select,  but  American  literature  upon  obstetrics  is  not  yet  rounded  out 
and  complete  in  all  its  proportions.  Dr.  Parvin  contributes  much  to  com- 
plete the  structure,  and  Ave  may  now  begin  to  say  that  we  have  upon  the 
subject  a  national  literature.  Upon  a  science  so  broad  as  obstetrics  it 
may  be  difficult  to  define  how,  in  any  sense,  it  can  be  national  in  char- 
acter. This  is  no  place  to  discuss  the  matter ;  but  the  literature  upon 
that  or  any  other  subject  may  be  of  such  a  broad  and  original  character 
as  to  afford  a  consensus  of  opinion  that  is  truly  national.  We  may  go 
even  further,  and  assert,  without  danger  of  inviting  contradiction,  that 
environment  and  social  condition  may  exist  as  prime  factors  in  modify- 
ing to  a  degree  equal  to  national  characteristics  many  of  the  phenomena 
of  that  science  called  obstetrics. 

Dr.  Parvin  begins  his  treatise  in  the  good,  old  classical  way  of  ground- 
ing his  readers  in  elementary  anatomy  and  embryology.  A  departure 
from  this  order  would,  by  some  reviewers,  be  regarded  as  an  innovation, 
but  we  believe  that  some  obstetrical  author  of  the  future  will  thus  inno- 
vate. It  is  perfectly  proper  to  regard  the  young  obstetrical  reader  as 
being  in  need  of  some  special  instruction  concerning  the  female  pelvis  and 


172 


EE  VIEWS. 


its  contents,  but  one  must  be  careful  not  to  do  the  young  reader  harm 
rather  than  good.  Dr.  Parvin  takes  a  cut  from  a  plate  by  Sappey  of  the 
situation  and  relations  of  the  uterus,  in  which  the  uterine  axis  is  made  to 
conform  to  the  axis  of  the  upper  pelvic  strait,  except  that  the  uterine 
fundus  is  slightly  posterior  to  the  line  of  the  latter.  As  usual  in  this  time- 
honored  illustration  the  bladder  and  rectum  are  in  a  distended  condition. 
The  reader  may  protest  against  the  notice  of  such  a  trifle,  but  it  is  not  by 
any  means  a  light  matter.  The  mass  of  students  and  practitioners  have 
not  original  and  costly  monographs  within  reach  to  correct  an  error  of  this 
sort,  especially  as  all  the  text-books  upon  diseases  of  women  in  English, 
with  one  honorable  exception,  reproduce  an  illustration  of  the  same 
general  character.  The  reviewer  well  remembers  that  once  upon  a  time, 
while  giving  evidence  upon  the  stand,  an  unfriendly  advocate  held  Play- 
fair's  very  good  book  under  his  gaze  with  this  same  cut,  or  one  like  it, 
uppermost,  and  asked  him  if  that  was  a  correct  illustration  of  the  natural 
relation  of  the  pelvic  viscera.  "  No,  sir,  it  is  not,"  was  promptly  answered. 
"  What !"  with  a  triumphant  glance  at  the  jury, "  do  you  differ  from  this 
distinguished  English  authority,  and  from  Dr.  A.,  and  Dr.  B.,who  have 
just  sworn  that  this  is  a  correct  representation  of  these  parts  ?"  Surely 
this  advocate  could  not  be  blamed,  nor  could  Dr.  A.,  or  Dr.  B.  But  we 
must  confess  to  a  certain  degree  of  feeling  toward  Playfair,  who  knew 
better,  and  one  may  fancy  that  the  well-executed  woodcut  in  Parvin  will 
serve  the  same  ignoble  end.  Our  author  still  further  confuses  his  younger 
readers  by  giving  an  approximately  correct  pelvic  section  copied  from 
Schultz,  without  a  word  of  comment  to  guide  the  reader  to  a  correct 
conclusion.  The  two  opening  chapters  devoted  to  the  subject  already 
noticed  are  well  illustrated,  and  compiled  from  the  latest  authority. 
We  notice  but  one  omission,  and  that  is  the  correction  of  Hart,  as  to  the 
distribution,  of  mucous  membrane  upon  the  nymphs  and  body  of  the 
clitoris,  which  differs  materially  from  accepted  descriptions,  which  inde- 
pendent study  by  others  has  confirmed. 

The  third  chapter  upon  puberty,  ovulation,  and  menstruation  is  inter- 
estingly written.  At  the  outset  our  author  expresses  himself  in  a  way 
that  one  choice  in  the  use  of  terms  would  object  to.  Incidentally  he 
defines  menstruation  as  a  hemorrhage  from  the  uterus  that  occurs  at 
definite  times,  concerning  which,  we  all  know  that  menstruation  in  its 
normal  expression  is  not  a  hemorrhage.  Justice  requires  us  to  admit 
that  he  does  not  use  the  term  in  its  exact  sense,  but  in  an  illustrative 
way ;  in  other  words,  it  is  a  figure  of  speech.  While  upon  the  use  of 
terms  it  would  be  as  well  here  as  elsewhere,  to  speak  of  the  style  of  our 
author.  Nothing  in  the  way  of  medical  writing  can  be  more  clear  or 
simple.  Most  medical  writers,  unless  they  are  stricken  by  Hugo  or 
Carlyle,  cannot  be  said  to  have  any  style ;  but  concerning  our  author,  if 
we  were  to  apply  to  it  the  standard  of  old  Hugh  Blair,  simplicity  is  the 
only  term  to  convey  an  idea  of  the  directness  of  expression,  the  freedom 
from  ornament,  and  the  painstaking  effort  to  avoid  confusion  of  expres- 
sion. We  fail  to  recall  an  instance  in  the  book  in  which  he  has  tried  to 
clear  up  a  doubtful  meaning  by  turning  the  idea  into  another  expression, 
which  is  a  very  common  fault  in  text-books.  Another  feature  that  will 
strike  the  reader  is  the  careful  way  in  which  excessive  technicalities  have 
been  avoided.  Our  author  has  a  correct  idea  of  a  technical  word.  Its 
proper  use  is  not  to  convey  a  meaning  but  to  give  a  definite  form  to  an 
expression.    Its  use  is  to  limit  and  so  direct  the  sense  that  but  one  con- 


PARVIN,  SCIENCE   AND   ART  OF    OBSTETRICS.  173 


structioii,  and  that  sharply  defined  within  the  limits  of  a  single  word, 
can  be  placed  upon  the  sentence.  As  an  instance,  but  not  specially  to 
illustrate  the  last  comment  above,  take  the  following : 

"  The  physician,  whose  duty  is  not  only  to  heal  the  sick,  but  also  to  prevent 
disease  and  to  improve  the  race,  and  hence  one  (who)  must  be  a  teacher  of  men 
and  women,  should  teach  sound  doctrine  in  regard  to  the  injurious  results  of 
precocious  marriage.  Mothers  especially  ought  to  be  taught,  though  some 
have  learned  the  lesson  by  their  own  sad  experience,  that  puberty  and  nubil- 
ity are  not  equivalent  terms,  but  stand  for  periods  of  life  usually  separated  by 
some  years ;  the  one  indicates  capability,  the  other  fitness  for  reproduction." 

It  would  have  been  a  blessing,  not  in  disguise,  if  the  text-books  writ- 
ten according  to  law  to  teach  physiology  in  the  common  schools  of  New 
York,  could  have  been  expressed  in  such  direct  and  simple  English. 
One  will  notice  the  omission  of  pronouns,  which  is  almost  a  mannerism 
of  the  author,  which  seems  to  come  from  his  desire  to  construct  a  sen- 
tence without  a  superfluous  word.  On  the  following  page,  what  can  be 
more  simple,  exact,  and  graphic  than  the  following  description  of  the 
corpus  luteum  f 

"  The  ovisac — its  size  lessened  by  the  escape  of  the  ovule  and  its  surround- 
ing granular  matter,  and  of  serous  fluid,  and  the  rent  through  which  these 
passed  closing — undergoes  certain  changes,  which  result  in  its  obliteration, 
the  most  notable  of  these  being  the  formation  of  the  corpus  luteum,  or  yellow 
body." 

Would  the  young  reader  of  that  ever  forget  the  cause  and  nature  of 
this  little  spot?  Neither  our  author,  nor  the  reader  must  put  a  wrong 
meaning  upon  what  our  sum  total  of  his  style  amounts  to ;  it  is  compli- 
mentary, not  invidious.  It  is  this,  by  way  of  comparison ;  Lusk's 
treatise  is  one  for  the  mature  practitioner ;  Parvin's  for  the  student  or 
undergraduate.  Not  that  one  is  more  elementary  than  the  other,  but 
one  is  better  fitted  by  happy  simplicity  of  expression  to  convey  an  idea, — 
to  break  the  ground,  as  it  were,  in  the  process  of  education.  The  result 
is  that  we  know  of  no  book  that  comprises  a  greater  mass  of  facts  within 
seven  hundred  pages  than  the  one  before  us. 

Upon  menstruation,  concerning  the  nature  of  which  there  are  some 
well-grounded  uncertainties,  if  such  an  expression  can  be  allowed,  our 
author  permits  no  liberties.  If  he  has  any  pet  theory  of  his  own,  he  evi- 
dently regards  an  educational  treatise  as  no  place  for  its  exposition.  In 
one  sense  he  is  right,  but  he  must  not  forget  that  he  is  a  guide  as  well  as 
an  educator,  and  that  even  a  word  of  doubt  or  dissent  is  a  useful  step- 
ping-stone to  the  truth. 

Part  second  opens  with  the  subject  of  pregnancy,  of  which  the  first 
chapter  is  given  to  conception,  early  development  of  the  impregnated 
ovule,  formation  of  deciduous  membranes,  and  the  fcetal  appendages, 
and  gives  us  a  resume  of  the  latest  theories. 

The  second  chapter  is  devoted  to  the  anatomy  and  physiology  of  the 
embryo.  Very  properly  the  author  insists  upon  the  distinction  between 
foetus  and  embryo  which  is  so  frequently  confounded.  Dr.  Parvin 
adheres  to  Pajot's  law  concerning  fcetal  presentation.    He  says : 

"Studying  Pajot's  law  as  it  relates  to  the  presentation  alone,  we  find  in  the 
painless  contractions  of  the  uterus  in  pregnancy,  in  the  varying  abdominal 
pressure,  and  in  the  changes  of  position  of  the  mother,  which  have  more  or 
less  action  upon  the  foetus,  the  conditions  of  movement  and  rest ;  the  foetus 


174 


REVIEWS. 


presents  more  of  a  rounded  than  an  angular  surface,  and  after  the  secretions 
of  the  sebaceous  glands  begin,  this  surface  is  smooth,  slippery,  and  thus  the 
amniotic  assisting,  the  accommodation  of  the  contents  to  the  container  is 
effected.  This  accommodation  fails  in  those  months  of  pregnancy  when  the 
uterus  is  very  much  larger  than  the  foetus.  Thus  Veits's  statistics  show  that 
in  247  deliveries  between  the  first  of  the  fifth  and  sixth  months,  the  head 
presented  in  140,  the  pelvis  in  95,  and  the  trunk  in  12.  In  the  foetus  be  dead 
and  macerated,  one  of  the  conditions  of  the  law  fails,  the  content  is  no  longer 
a  solid  body,  and  statistics  show  that  in  very  nearly  one-half  of  the  cases 
when  delivery  takes  place  before  six  months  the  pelvis  presents." 

Many  corroborative  facts  can  be  brought  to  bear  upon  the  quite 
general  utility  of  Pajot's  law.  Presentation  of  the  pelvis  is  common  in 
the  hydrocephalic  foetus  and  evidently  in  obedience  to  the  law  of  ac- 
commodation. In  twin  pregnancies  there  is  a  defect  in  this,  with  cor- 
responding variations  in  errors  of  position.  In  hydramnios  the  law  of 
accommodation  is  violated,  so  that  breech  and  lateral  presentations  are 
common. 

The  author  refers  to  the  discussion  in  the  New  York  Obstetrical 
Society  of  foetal  narcotism  secondary  to  that  of  the  mother.  The  matter 
must  now  be  regarded  as  beyond  dispute.  Porak's  experiments  are 
absolutely  conclusive.  In  one  instance  in  which  one  grain  of  quinine 
was  given  to  the  parturient  woman,  the  urine  of  the  child  born  an  hour 
and  a  half  afterward  showed  the  presence  of  the  drug.  Ruige  made  a 
similar  observation.  If  the  child  in  utero  can  suffer  from  intermittent 
fever  the  remedy  is  at  hand. 

The  third  chapter  is  devoted  to  changes  in  the  maternal  organism 
and  to  multiple  pregn?„ncy.  Concerning  the  latter,  our  author  adheres 
to  the  possibility  of  super-fecundation  in  the  human  female,  adducing 
the  familiar  illustration  of  the  white  woman  with  twins,  one  white,  the 
other  a  mulatto ;  or  its  converse,  the  black  woman  with  a  white  and  a 
mulatto  child.  It  appears  to  us  much  more  reasonable  to  regard  them 
as  instances  of  atavism,  which  is  so  very  common  in  cases  of  mixed 
blood.  At  least  in  all  phenomena  of  this  nature  the  contrary  of  mixed 
races  must  be  proved  before  we  can  offer  superfecundation  as  an  ex- 
planation. The  latter  aberration  of  fecundation  is  no  more  marvellous 
than  that  of  superfoetation. 

The  fourth  chapter  upon  the  signs  and  diagnosis  of  pregnancy  is  very 
compact,  and  well  written  with  no  long  exposition  of  the  various  signs, 
and  is  an  excellent  chapter  for  the  student.  The  author's  MS.  was  so 
far  out  of  his  hand  at  this  point  that  he  evidently  could  not  include 
Hegar's  sign  of  pregnancy,  one  of  the  very  last  of  any  value. 

In  the  fifth  chapter  the  author  enters  largely  into  the  medico-legal 
aspects  of  the  duration  of  pregnancy,  the  proof  of  previous  pregnancies, 
and  missed  labor.  At  the  conclusion  of  the  section  he  gives  a  summary 
of  the  legal  bearings  of  the  duration  of  pregnancy  by  James  I.  Baker, 
Esq.,  of  Indianapolis,  which  is  the  best  exposition  of  the  subject  to  be 
found  in  any  text-book  up  to  the  present  time,  not  excluding  even 
treatises  on  medical  jurisprudence,  as  it  is  a  statement  of  decisions  in  the 
various  State  courts.  Mr.  Baker's  brief  upon  the  subject  will  evidently 
find  a  permanently  useful  field  in  the  literature  of  this  vexed  question. 

The  management  of  pregnancy,  the  pathology  of  the  condition,  and 
eclampsia,  are  the  subjects  of  Chapters  VI.,  VII.,  VIII.,  and  IX.  Re- 
lating to  the  latter,  the  author  alludes  to  the  quite  recent  studies  of 


PARVIN,  SCIENCE   AND   ART   OF   OBSTETRICS.  175 

Doleris  and  Butte,  They  have  found  toxic  ptomaines  in  the  bloo  l  of 
eclamptics,  which  may  cause  the  disease.  If  this  view  of  the  origin  of 
the  convulsions  is  confirmed  by  future  investigations,  we  may  put  to  one 
side  the  exclusive  idea  of  renal  origin.  It  is  to  be  regretted  that  our 
author  is  so  non-committal  upon  the  treatment  of  eclampsia.  In  this 
grave  accident  the  student  needs  an  energetic  guide.  It  is  not  so  much 
a  single  question  as  to  what  is  safe  and  that  only,  but  what  can  be  done 
that  is  not  more  dangerous  than  the  disease  itself?  For  instance,  our 
author's  most  hearty  approval  of  bloodletting  is,  that  "  the  abstraction 
of  blood  gains  time  for  the  use  of  other  therapeutic  means,  and  prevents 
the  consequences  of  congestion ;  the  abstraction  of  ten  to  fifteen  ounces 
of  blood  can  only,  in  exceptional  cases,  be  immediately  or  remotely  inju- 
rious." Our  friend,  Dr.  Clark,  of  Oswego,  in  his  energetic  use  of  mor- 
phia receives  no  word  of  favorable  comment,  although  it  is  a  practice 
that  is  gaining  ground,  and  giving  excellent  results.  The  author  leans 
to  the  free  use  of  chloral,  a  drug  that  is  certainly  as  potentially  danger- 
ous as  morphia. 

In  Chapters  X.  and  XI.  diseases  of  the  sexual  organs  and  of  the  ovum 
are  described.  The  only  point  necessary  to  call  to  the  attention  of  the 
reader  is  the  author's  method  of  dealing  with  retained  placenta  after 
abortion  at  the  third  month.  He  is  conservative  and  cautions  against 
too  active  interference,  quoting  approvingly  Churchill's  conclusion, 
that  they  may  be  safely  left  to  nature.  There  is  surely  no  danger  in 
proper  removal  of  placental  fragments,  and  the  sum  of  opinion  in  this 
age  of  clean  surgery,  not  to  say  midwifery,  is  in  favor  of  removing  all 
sources  of  septic  infection.  Surely,  of  all  organs  of  the  body,  and  of  all 
material  that  may  become  incarcerated  within  it,  no  one  is  so  prone  to 
absorb,  and  nothing  is  so  certain  to  decompose,  as  a  uterus  with  retained 
fragments.  That  we  do  remove  them  days  after  the  proper  time  for 
expulsion,  filthy  beyond  description,  and  the  woman  show  no  evidence 
of  blood-poisoning,  is  no  argument  to  leave  these  cases  to  nature.  Cases 
have  came  to  the  writer's  knowledge  in  which  the  retained  mature  pla- 
centa was  treated  in  the  same  Fabian  method.  Now,  as  a  matter  of 
fact,  women  do  not  often  die  from  blood-poisoning  due  to  decomposing 
placental  fragments  after  spontaneous  absorption,  and  it  is  upon  this 
tolerance  that  the  treatment  by  non-interference  is  based  ;  but  they  do 
in  some  instances  die,  and  there  is  a  special  liability  to  this  result  in 
instances  of  forced  abortion,  so  that  it  is  doubtful  policy  on  the  part  of 
an  educator  to  be  conservative  in  his  teaching  upon  this  subject.  If 
placental  tissue,  either  in  fragments  or  entire,  is  left  longer  than  ten  or 
twelve  hours  it  is  sure  to  be  decomposed,  the  result  of  bacterial  invasion  ; 
and  the  line  of  non-interference  ought  to  be  drawn  about  them  as  a 
matter  of  time  Dr.  Parvin  may  be  right  as  a  teacher  to  deprecate  the 
use  of  the  curette  and  other  instrumental  interference  when  the  case 
presents  no  evidence  of  danger.  The  method  he  advises,  that  of  the 
finger,  is  a  safe  and  efficient  one,  but  in  case  the  cervical  canal  is  closed, 
so  that  the  finger  cannot  be  introduced  into  the  uterine  cavity,  as  it  very 
frequently  is  after  twenty-four  hours,  it  is  not  necessary  to  resort  to 
gradual  dilatation,  as  the  author  advises,  with  tents,  but  rapid  dilatation 
is  safer  and  better,  and  may  be  almost  painless  with  a  proper  instrument 
and  gentleness  in  manipulation. 

Chapter  XII.  is  devoted  to  the.  study  of  ectopic  development  of  the 
ovum  and  placenta.    A  concise  but  excellent  summary  of  the  symptoms 


176 


EEVIEWS. 


of  the  former  condition  is  given.  The  treatment  by  the  faradic  current  is 
assigned  an  important  place  in  the  treatment.  It  is  to  be  regretted  that 
more  exact  rules  for  the  application  of  the  current  to  arrest  foetal  life 
are  not  given.  Garrigue's  directions,  that  a  moderate  current  for  ten 
minutes  at  a  time  be  employed,  are  of  very  doubtful  utility.  The  writer  has 
just  been  through  an  experience  of  this  kind,  and  the  method  of  Garrigues 
as  quoted  by  our  author  would  have  been  useless.  It  needs  no  argu- 
ment to  assert  that  the  faradic  electricity  is  used  to  destroy  life.  The 
fact  that  this  life  is  of  low  grade  does  not  imply  that  it  will  succumb 
to  a  mild  form  of  the  agent,  passed  for  a  short  time.  Foetal  life,  to  illus- 
trate, is  of  as  active  a  nature  as  that  of  vegetable  life,  and  it  is  known 
by  experiment  that  in  the  majority  of  instances  a  powerful  current  is 
needed  to  cause  fatal  molecular  changes  in  the  latter.  Another  fact, 
which  every  one  who  has  used  faradic  electricity  about  the  female  pelvis 
must  have  noticed,  is  the  great  tolerance  to  the  current  in  these  parts. 
In  one  instance  under  the  observation  of  the  writer,  the  full  strength  of 
a  large  induction  coil,  with  a  current  from  two  zinc-carbon  cells,  was 
used  with  but  little  expression  of  pain  from  the  patient.  It  was  impossi- 
ble for  the  operator  to  hold  the  electrodes  in  his  hands.  A  secondary 
current  of  this  strength  was  passed  through  the  foetal  cyst  for  an  hour. 
Several  seances  of  this  character  were  had  before  it  could  be  said  that 
foetal  life  was  destroyed. 

A  w7ord  as  to  the  evidence  that  the  current  has  done  its  work.  This 
ought  to  be  looked  for  in  the  cyst  rather  than  to  abatement  of  the 
rational  signs  of  pregnancy  or  to  retrograde  changes  in  the  breasts. 
The  most  important  are  lessened  tension  in  the  cyst,  which  is  observed 
long  before  the  most  delicate  touch  can  assure  the  operator  that  there  is 
actual  diminution  in  size.  The  situation  and  character  of  the  cyst  are 
such  that  no  manner  of  touch  can  measure  it,  it  simply  leads  the  observer 
to  exert  a  scientific  imagination  that  the  cyst  is  diminishing.  Next, 
the  attacks  of  pain  ceases.  This  will  be  noticed  to  coincide  with  the 
lessened  tension  of  the  cyst  wall,  and  is  probably  due  to  the  relief 
of  pressure  upon  tissues  but  little  tolerant  of  tension,  and  with  but  scant 
time  to  acquire  adjustment  to  the  morbid  change.  It  is  to  be  regretted 
that  there  is  no  accurate  method  of  measuring  the  strength  of  the  sec- 
ondary current  of  an  induction  coil ;  if  there  were,  it  would  be  a  very 
simple  matter  to  designate  the  electro-molecular  force  necessary  to  de- 
stroy foetal  life  in  ectopic  pregnancy ;  but  in  the  absence  of  such  a 
guide  the  writer  would  urge  a  strong  current  and  a  long  seance. 

At  Part  III.  the  author  begins  the  study  of  labor.  Eight  concise, 
well-considered  chapters  dispose  of  the  whole  subject,  which  is  given 
further  value  by  a  profusion  of  well-executed  wood-cuts.  Our  author 
presents  nothing  new  in  the  division  of  his  subject.  Abdominal  palpa- 
tion is  well  described  and  illustrated  as  it  is  now  in  all  the  recent  hand- 
books. We  have  great  faith  in  instruments  of  precision  and  of  their 
influence  upon  the  future  of  medical  science ;  but  it  is  quite  an  innova- 
tion on  the  general  conservative  tone  of  the  book  to  have  our  author 
give  the  very  ingenious  instrument  of  Dr.  Deaman,  called  a  parturiometer, 
a  very  prominent  place  and  give  a  few  lines  of  comment  rather  unfor- 
tunately expressed.    He  says : 

"The  parturiometer  indicates  when  it  is  proper  to  break  the  membranes, 
when  the  cervix  is  fully  dilated;  when  the  application  of  instruments  becomes 
necessary." 


PARVIN,  SCIENCE   AND   ART   OF  OBSTETRICS.  177 


There  must  certainly  be  something  in  Dr.  Deaman's  instrument  that 
will  cause  such  a  statement  from  our  author.  We  had  supposed  that 
in  all  the  above  indications  the  "  when  "  was  more  or  less  of  an  intel- 
lectual process,  and  while  instruments  of  this  character  are  useful  they 
will  rather  serve  the  purpose  of  exact  study  of  phenomena  than  take  a 
practical  place  at  the  bedside.  Dr.  Deainan  contributes  a  page  of 
description  of  his  instrument  which  is  very  interesting. 

The  author  enters  fully  into  the  subject  of  anaesthesia.  In  this  period 
of  multiplicity  of  agents  of  this  character  chloroform  is  given  the  chief 
place.  It  is  evidently  Dr.  Parvin's  practice  to  employ  it,  although  the 
reader  gains  this  idea  by  inference  rather  than  directly.  Chloral  in  the 
first  stage  of  labor  is  mentioned,  and  probably  serves  as  useful  a  purpose 
as  general  anaesthesia  in  the  second.  It  is  surprising  how  slowly  anaes- 
thesia in  obstetrics  has  gained  its  place,  and  it  is  far  from  being  in  gen- 
eral use  to-day.  The  writer  must  confess  to  having  had  a  great  reluc- 
tance in  using  it  early  in  labor,  and  confined  its  use  to  the  expulsive 
stage  ;  but  just  before  withdrawing  from  obstetric  practice  it  was  resorted 
to  in  every  case,  affording  deep  regret  that  for  fifteen  years  he  had  given 
it  but  little  use.  It  will  certainly  become  generally  employed  when  such 
a  conscientious  teacher  as  Dr.  Parvin  advises  it. 

A  great  variety  of  statements  from  various  authors  is  given  concern- 
ing the  care  of  the  perineum,  and  the  student  must  be  left  in  considerable 
doubt  as  to  the  better  way ;  a  careful  reading  leads  to  the  opinion  that 
it  is  the  author's  practice  to  support  this  part  during  the  expulsion  of 
the  head.  Chloroform  is  a  better  protection  than  the  methods  of  sup- 
port given  in  the  text,  as  an  anaesthetic  prevents  the  energetic  voluntary 
efforts  on  the  part  of  the  mother. 

Immediate  ligation  of  the  cord  is  advised ;  or,  at  least,  what  the  advo- 
cate of  late  ligation  would  call  immediate.  He  says,  "  when  the  child 
breathes  freely,  and  the  pulsation  lessens  in  force,  one  need  not  wait. 
In  regard  to  waiting  until  all  pulsation  has  ceased,  one  might,  in  some 
cases,  wait  until  all  patience  as  well  as  pulsation  has  ceased."  None 
but  the  ardent  advocates  of  late  ligation  can  object  to  this.  It  will 
afford  comfort  to  mothers  and  old  nurses  to  know  that  the  "  belly  band" 
is  advised  in  dressing  the  child.  It  cannot  possibly  do  any  harm  to 
apply  a  bandage  properly  to  the  abdomen  of  a  newly  born  child,  and 
yet  it  is  a  recent  "  fad"  to  leave  it  off.  The  binder  to  the  mother  also 
finds  a  consideration  at  our  author's  hand,  and  young  practitioners  had 
better  followT  the  advice.  It  is  a  proper  and  comfortable  article  of  dress, 
and  ought  to  be  so  considered. 

The  chapter  upon  anomalies  is  contributed  by  Dr.  Henry  Morris,  and 
is  well  written  and  illustrated. 

The  puerperal  state  is  considered  in  Part  IV.,  and  is  the  shortest 
division  of  the  book.  We  will  omit  all  review  of  this  section,  except 
that  wmich  relates  to  puerperal  septicaemia.  Whatever  may  be  the  debt 
of  surgery  to  antiseptics  that  of  obstetrics  is  equally  great,  and  a  teacher 
of  the  latter  must  now  occupy  no  doubtful  position  concerning  the 
sources  of  puerperal  sepsis.  We  can  find  no  fault  with  our  author  in 
this.    He  speaks  judicially,  but  positively  : 

"Independently  of  all  culture  experiments  and  inoculations,  and  micro- 
scopic examinations  of  the  uterine  and  vaginal  discharges  <>t'  sick  women  in 
childbed,  and  of  fluids  or  solids  of  women  dying  of  puerperal  septicaemia,  there 
are  some  reasons  which  make  it  very  probable  that  the  infectious  agent  is  a 

NO.  CLXXXVII. — JULY,  1887.  12 


178 


REVIEWS. 


living,  a  contagium  animatum,  rather  than  any  chemical  substance,  whether 
sepsis  or  ptomaine.  These  are,  the  very  minute  quantity  which  infects,  the 
rapidity  of  its  action,  and,  finally,  the  protective  power  of  germicidal  solutions. 
It  is  only  upon  the  hypothesis  of  a  living  poison  with  the  great  rapidity  of 
reproduction  which  low  forms  of  life  have,  that  we  can  readily  explain  the 
fact  of  dangerous  illness  being  so  soon  developed.  And  again,  if  we  cure  by 
using  injections  of  corrosive  sublimate,  or  of  carbolic  acid  in  solution,  it  seems 
more  rational  to  conclude  that  the  agent  has  destroyed  living  rather  than 
rendered  dead  matter  harmless.  Moreover,  the  demonstrated  dependence  of 
many  other  diseases  upon  germs  makes  it  probable  that  this  also  has  a  similar 
cause  

"The  microbes  which  are  most  constantly  found  in  puerperal  fever  are 
chain-like  micrococci,  and  in  many  cases  of  the  disease  where  these  were  not 
discovered  it  is  possible  they  were  still  present,  but  methods  of  examination 
failed.  Similar  micrococci  have  been  found  in  erysipelas,  scarlatina,  and  in 
diphtheria,  but  similarity  does  not  prove  identity,  and  it  may  be  that  careful 
culture  experiments  will  show  that  which  the  microscope  has  failed  to  do,  an 
essential  difference  in  these  cocci.  We  must  remember  that  microbiology  is 
still  in  its  infancy,  and  the  relation  of  microorganisms  to  disease  only  begin- 
ing  to  be  demonstrated,  and  therefore  we  are  willing  to  admit  that  the  chain  of 
evidence  is  not  yet  complete  which  connects  puerperal  fever  with  the  action 
of  microorganisms.  Conceding  this  origin  of  the  disease,  are  there  different 
microbes  for  the  different  varieties  of  the  disease?  Or  do  differences  arise 
from  the  quantity  introduced,  and  the  receptivity  of  the  subject,  and  the  time 
of  introduction  ?  A  plant  does  not  thrive  equally  well  upon  different  soils, 
nor  seeds  germinate  with  equal  rapidity  in  all  seasons,  and  why  not  admit 
equal  results  in  microbicum  maladies?  Scarlet  fever  in  different  epidemics 
and  in  different  subjects,  presents  grades  of  intensity  and  degrees  of  danger 
widely  separate,  yet  the  poison  is  one  and  the  disease  is  one.  The  origin  of 
an  epidemic  of  puerperal  fever  may  be  in  a  case  of  retained  placenta 
where  means  have  been  employed  to  remove  the  placenta,  these  means  failing 
to  make  the  delivery  complete;  in  a  day  or  two  the  lochia  become  offensive, 
the  woman  has  a  chill  followed  by  high  temperature  and  increase  in  the 
frequency  of  the  pulse.  Other  women  are  infected  from  this  patient  with 
different  forms  of  puerperal  fever,  scarcely  two  presenting  the  same  symp- 
toms. Here  then  is  a  common  cause,  but  various  results ;  one  fountain,  but 
many  streams. 

"  But  what  role  do  retained  clots,  or  as  in  the  instance  just  alluded  to,  do 
fragments  of  placenta  play  in  the  genesis  of  the  disease  ?  Are  they  innocent, 
so  that  it  is  a  matter  of  indifference  whether  they  remain  in  the  puerperal 
uterus?  No,  for  while  they  do  not  create  the  disease  they  furnish  the  nidus 
in  which  septic  germs  enter,  a  favorable  soil  for  their  development  and  mul- 
tiplication. 

"  Summary. — From  what  is  known  of  so-called  puerperal  fever  it  should 
not  be  regarded  as  a  specific  disease,  and  strictly  speaking  there  is  no  puer- 
peral fever,  that  which  is  so  denominated  being  a  febrile  affection  caused  by 
the  entrance  into  the  system  of  a  poison  from  without,  the  nature  of  which  we 
do  not  know,  the  entrance  taking  place  through  a  wound  of  the  uterus,  or  of 
some  part  of  the  vulvo-vaginal  canal." 

No  honest  bacteriologist  can  take  exception  to  this  well-expressed 
summary  of  Dr.  Parvin,  or  to  any  portion  of  the  above.  It  is  one  of 
the  best  expositions  upon  the  subject  in  any  text-book,  and  will  produce 
a  healthful  mental  impression  upon  students  and  practitioners.  To  those 
who  are  fond  of  a  well-turned  sentence  we  hold  the  following  up  as  one 
of  the  cleverest  in  medical  literature.  We  have  already  quoted  it,  but 
it  will  bear  repetition.  "It  seems  more  rational  to  conclude  that  the 
agent  has  destroyed  the  living  rather  than  rendered  dead  matter  harm- 
less."   It  is  the  gospel  of  disinfection,  and  the  whole  creed  of  the  bac- 


PARVIN,  SCIENCE    AND   ART   OF   OBSTETRICS.  179 


teriologists ;  but  it  provokes  the  reviewer  into  saying  that  it  is  a  great 
pity  that  a  man  who  can  express  a  conviction  so  fairly  and  so  happily 
has  not  thrown  authorities  and  their  conflicting  dogmas  to  the  winds 
and  become  Parvin  himself  from  cover  to  cover,  as  he  was  so  well  able 
to  do.  When  will  some  American  treat  the  subject  of  obstetrics  as 
Emmet  has  that  of  gynecology,  and  not  like  Lusk,  who  has  written  the 
best  German  work  on  obstetrics  in  the  English  language,  or  like  one 
not  yet  upon  the  shelves  of  our  library,  which  is  the  best  digest  upon 
the  subject  up  to  date. 

We  are  not  yet  through  with  our  author  upon  the  subject  of  antisep- 
tic midwifery.  Now  with  the  author's  clearly  expressed  views  upon  the 
subject  of  puerperal  infection  before  us,  we  are  prepared  to  say  that  pre- 
vention is  of  much  greater  utility  than  treatment.  In  fact,  what  physi- 
cian has  not  the  misfortune  of  knowing  how  useless  are  some,  if  not  all, 
of  the  best  laid  plans  of  medication,  and  even  disinfection,  in  the 
presence  of  this  disease  ?  We  have  seen  how  fully  in  line  with  the  most 
advanced  writers  Dr.  Parvin  is  upon  the  subject  of  antiseptic  midwifery; 
but  as  in  this  practical  part  of  his  treatise  we  have  to  consider  methods 
not  opinions,  let  us  inquire  how  perfect  are  his  methods  for  the  protection 
of  the  lying-in  woman.  Turning  back  to  his  chapter  upon  the  conduct 
of  labor  the  author  says : 

"Thorough  disinfection  of  the  room  which  the  patient  is  to  occupy  should 
be  made,  if  it  has  been  previously  occupied  by  one  suffering  with  scarlet  fever, 
with  erysipelas  or  diphtheria,  or  with  any  disease  attended  with  suppuration, 
as  uterine  cancer  in  its  advanced  stages ;  it  would  be  better,  indeed,  for  her 
lying-in  to  be  in  another  house,  or  other  room.  The  room,  too,  should  be 
free  from  the  effluvia  of  decaying  animal  matter.  If  there  be  any  sewer  com- 
munication in  it,  as,  for  example,  from  the  permanent  wash-stand,  that 
communication  should  be  for  the  time,  at  least,  cut  off.  The  obstetrician 
must  know  that  the  nurse  has  not  recently  been  in  attendance  upon  any  of 
the  forms  of  disease  that  have  been  mentioned  and  especially  upon  a  case  of 
puerperal  septicaemia." 

This  is  all  very  well  and  no  possible  exception  can  be  taken  to  it  so 
far  as  it  goes  ;  but  the  best  comment  we  can  make  upon  it  is  to  quote  from 
a  recent  paper  by  Prof  William  D.  Richardson,  of  Harvard,  published 
in  the  Boston  Medical  and  Surgical  Journal  for  January,  1887.  He  is 
writing  upon  the  use  of  antiseptics  in  obstetrics,  as  illustrated  in  the  Bos- 
ton Lying-in  Hospital : 

''The  various  changes  which  have  been  in  the  attempts  to  rid  the  hospital 
of  septicaemia,  have  been  the  results  of  careful  study  and  observation  on  the 
part  of  the  visiting  physicians,  and  after  many  anxious  consultations  on  the 
subject.  As  one  septic  case  occurred  after  another,  every  effort  was  made  to 
avoid  any  possibility  of  contagion  from  a  patient  presenting  symptoms  of  sep- 
tic infection  to  another.  Isolation  of  suspected  cases;  the  employment  of 
extra  and  special  nurses,  the  assignment  of  different  house-physicians  to  the 
infected,  and  to  those  whose  convalescence  seemed  normal;  the  use  of  every 
possible  precaution  to  insure  cleanliness,  the  providing  of  individual  bed-pans, 
syringes,  etc.,  constant  attention  to  ventilation  and  improvement  in  the  drain- 
age, were  among  the  methods  adopted.  Many  of  these  changes  seemed  to 
promise  improvement,  which,  however,  was  always  found  to  be  temporary. 
From  the  very  outset  the  staff  were  a  unit  in  the  belief,  even  then  not  generally 
accepted,  that  the  views  of  Semmelweiss  were  correct,  and  our  object  was  to  pre- 
vent the  entrance  of  septic  material  from  without,  and  the  prevention  of  the  ab- 
sorption of  septic  material  originating  within  the  uterus  and  generative  tract. 
With  this  latter  end  in  view,  we  soon  began  the  use  of  vaginal  injections. 


180 


REVIEWS. 


hoping  to  keep  disinfected  those  parts  especially  exposed  to  the  lochial  dis- 
charge, which  seemed  to  us  one  great  source  of  danger  within  the  patient 
herself.  These  were  subsequently  not  infrequently  combined  with  intra- 
uterine injections,  hoping  thereby  also  to  render  innocuous  the  clots  and 
placental  debris  within  the  uterine  cavity.  All  these  attempts  proved  futile, 
although  occasionally  it  did  seem  as  though  some  new  method  of  procedure 
which  we  adopted  was  at  last  to  offer  the  long  sought  for  relief.  The  respite 
was,  however,  only  temporary,  and  still  the  mischief  went  on. 

"In  the  middle  of  the  winter  of  1883  and  1884,  corrosive  sublimate  was  first 
tried,  not  only  as  a  vaginal  douche  but  also  for  the  disinfecting  of  the  hands 
of  the  attendants.  A  very  decided  improvement  followed  this  method  of 
procedure,  and  again  the  outlook  was  more  cheering.  Still  septicaemia 
remained  with  us,  but  in  a  more  modified  form  and  the  death-rate  fell 
decidedly.  Then  came  the  announcement  of  Robert  Koch's  investigations  of 
bacteria,  and    ....    we  determined  to  change  our  whole  system." 

We  will  now  return  to  our  author  and  continue  the  quotation  from 
the  next  paragraph  to  the  last  on  the  conduct  of  labor. 

"  It  is  well  for  the  parturient  to  take  a  warm  bath  at  the  beginning  of  labor, 
and  afterward  to  have  the  external  genital  organs  washed  with  a  two  or  three 
per  cent,  solution  of  carbolic  acid ;  when  the  labor  is  protracted,  a  similar 
solution  may  be  used  as  a  vaginal  injection  once  or  oftener.  A  three  to  five 
per  cent,  solution  may  be  used  by  the  physician,  and  by  the  nurse  for  washing 
their  hands.  The  former  not  only  should  use  an  antiseptic  solution  in  whicli 
he  washes  his  hands  before  each  examination,  but  also  an  antiseptic  ointment 
applied  to  the  fingers  before  introduction  into  the  vagina  ;  this  may  be  carbo- 
lized  cosmoline,  or  iodoform  and  cosmoline,  or  an  ointment  may  be  made  by 
incorporating  with  an  ounce  of  cosmoline,  one-tenth  part  of  thymol." 

As  the  latest  expression  upon  this  vastly  important  subject  of  anti- 
septics in  labor,  and  to  contrast  the  very  material  difference  in  methods, 
we  will  introduce  one  more  extract  from  Prof.  Richardson.  It  relates 
solely  to  the  conduct  of  labor. 

"  In  every  case  the  genital  and  surrounding  parts  are  washed  with  a  solu- 
tion of  bichloride  of  mercury  (-g^Vo)-  A  basin  containing  the  same  solution 
and  a  nail-brush  is  placed  on  a  stand  by  the  side  of  the  bed.  The  physician 
and  nurse  in  attendance  disinfect  their  hands  every  time  they  have  occasion 
to  examine  the  patient  or  touch  the  neighborhood  of  the  vulva.  The  examin- 
ing finger  is  smeared  with  an  ointment  made  of  one  part  of  the  oil  of  euca- 
lyptus and  seven  parts  of  vaseline.  A  vaginal  injection  of  the  corrosive 
sublimate  solution  is  given  at  the  beginning  of  labor,  and  this  is  repeated 
when  circumstances  permit  at  the  end  of  the  first  stage.  As  the  head  dis- 
tends the  perineum  and  is  expelled  the  parts  are  kept  clean  by  the  use  of 
charpie  dipped  in  the  mercurial  solution.  After  the  birth  of  the  child,  no 
undue  haste  is  made  to  bring  about  the  expulsion  of  the  placenta.  This  is 
effected,  if  possible,  by  Crede's  method  of  expression,  great  care  being  taken 
not  to  introduce  the  hand  within  the  vulva,  if  such  a  procedure  can  be 
avoided.  The  original  injection  is  repeated,  and  the  antiseptic  pad  is 
applied." 

It  is  by  such  means  as  the  above  that  the  dark  picture  of  septic 
infection  has  been  changed  and  lighted  up.  It  proves  that  infection 
comes  from  without ;  that  its  introduction  can  be  prevented,  and  that, 
as  a  prophylaxis,  it  is  as  complete  as  vaccination  is  to  smallpox.  Con- 
trasting the  two  extracts,  it  shows  that  our  author  is  right,  and  that  he 
believes  in  the  best  teachings  of  the  bacteriologists ;  but  his  methods  are 
doubtful.  A  two  or  three  per  cent,  solution  of  carbolic  acid  has  been 
demonstrated  to  have  no  more  value  as  a  germicide  than  clean  water. 


PARVIN,  SCIENCE    AND  ART   OF   OBSTETRICS.  181 


But  we  do  not  bring  this  up  as  a  critical  matter.  Our  author  is  treating 
antiseptic  midwifery,  and  anything  that  would  lead  the  student  or  prac- 
titioner into  the  false  security  of  half  measures  is  a  fault  equally  as  great 
as  not  to  teach  it  at  all.  This  is  a  practical  matter.  Opinion  has  nothing 
to  do  with  it.  Demonstration  has  made  it  clear  as  the  sun  at  noon-day, 
and  it  is  therefore  a  question  of  methods,  and  those  methods  by  which 
the  most  perfect  results  have  been  attained  are  those  which  ought  to  be 
taught.  The  opinion  that  one  may  have,  that  one  procedure  is  as  good 
as  another,  has  nothing  to  do  with  it  if  the  two  methods  have  not  been 
put  to  equal  tests.  There  is  a  certain  moral  responsibility  in  teaching 
that  reaches  such  a  high  level  that  one  may  try  in  vain  to  attain  it  by 
the  force  of  opinion.  He  reaches  this  altitude  by  facts,  surrounds  him- 
self with  them  as  with  an  atmosphere,  and  lifts  up  to  his  own  level  all 
who  follow  after. 

The  author  resumes  the  subject  of  antiseptics  in  describing  the  treat- 
ment of  puerperal  septicaemia  in  which  further  prophylactic  measures 
are  followed  in  the  convalescence,  while  his  remedial  measures  are  of  an 
active  antiseptic  nature,  and  in  all  of  which  he  is  in  accord  with  the 
best  teachings.  In  all  that  has  been  said  of  a  critical  character  above 
wre  wish,  in  no  way  to  detract  from  the  real  value  of  this  important 
section  of  his  book.  In  fact,  it  may  be  said  to  be  in  advance  of  any 
recent  text-book ;  but  since  the  latest  American  text-book  very  material 
advances  have  been  made  upon  this  subject,  and  the  practitioner  to  be 
properly  instructed  should  have  a  practical  knowledge  of  the  best 
methods  of  maternities  in  order  to  judge  how  perfect  he  must  make  his 
antiseptic  details  at  the  bedside. 

The  fifth  and  concluding  part  is  devoted  to  obstetric  operations,  be- 
ginning with  the  induction  of  abortion,  premature  labor,  and  turning. 
The  latter  is  presented  in  accordance  with  the  precepts  of  Dr.  Samuel 
Sloan.  The  instructions  as  to  turning  are  very  simple  and  practical, 
and  will  serve  to  do  away  with  the  fears  of  the  young  practitioner  lest 
he  gets  hold  of  the  wrong  foot. 

The  forceps  are  studied  in  the  second  chapter.  There  is  a  well  writ- 
ten history  of  the  instrument,  illustrated  with  cuts  of  the  older  and  later 
forms,  followed  by  the  theory  of  the  forceps  and  the  mechanical  princi- 
ples involved  in  their  application  as  levers,  tractors,  and  rotators. 
Chapter  VIII.  disposes  of  the  indications  for  the  application  of  the 
forceps  and  the  rules  governing  their  use  in  general,  followed  by  special 
instructions  in  different  presentations  and  positions.  This  chapter  is 
one  of  the  most  practical  in  the  book,  and  too  much  praise  cannot  be 
awarded  the  author  for  the  simple  and  clear  manner  in  which  this 
usually  difficult  subject  is  disposed  of.  The  application  of  the  forceps 
is  so  simply  and  clearly  described  that  the  least  learned  practitioner  can 
understand  it.  It  is  not  always  so,  as  a  very  recent  instance  will  show, 
in  which  a  New  York  reviewer  got  so  tangled  up  with  his  author  that  he- 
could  not  understand  whether  he  meant  the  right  or  left  thig"h  of  the 
mother,  or  his  own  right  or  left  hand.  We  read  and  reviewed  the  same 
description  and  thought  it  a  very  good  one;  but  as  the  reviewer  was  a 
very  learned  man,  we  always  thought  it  was  stupid  on  our  part  not  to 
confess  to  an  equal  degree  of  confusion. 

Chapters  IV.  and  V.  conclude  the  book,  and  are  devoted  to  the  sub- 
jects of  Embryotomy  and  the  Cesarean  operation  and  its  substitute's. 
The  latter  will  alone  detain  us.    At  the  opening  of  the  chapter  we  are 


182 


REVIEWS. 


startled  by  a  table  compiled  by  Dr.  Harris  showing  the  strange  fatality 
attending  this  operation  in  the  United  States ;  no  mothers  saved  here, 
while  in  Germany,  84  per  cent,  of  the  mothers  were  saved  (25  operations, 
4  deaths),  in  the  past  year. 

"Leopold  operated  for  the  tenth  time  in  June,  1886.  This  gives  him  the 
loss  of  one  woman  in  ten,  or  from  his  hospital,  a  saving  of  ten  women  and 
three  children  from  eleven  operations.  Now  if  such  success  could  be  obtained 
by  practitioners  generally,  craniotomy  upon  the  living  foetus  would  soon  be- 
come unknown." 

It  is  not  a  little  singular  that  after  various  improvements  in  the  oper- 
ation, we  have  as  the  best  method  of  operating,  returned  to  the  so  called 
improved  Cesarean  operation,  which  is  the  old  way  of  operating, 
nothing  more.  It  is  simply  done  more  carefully,  with  more  hope  in  it. 
In  one  operation,  we  remember  hearing  one  of  the  physicians  present 
urge  the  operator  to  take  less  time  to  clean  the  abdominal  cavity  as  the 
woman  would  die  any  way ;  and  that  seems  to  be  the  spirit  in  which  the 
operation  is  often  made.  Now,  the  improved  operation,  as  described  by 
our  author,  who  follows  Potacki,  is  simply  the  old  operation  made  with 
more  care,  as  to  suturing  the  uterine  wound  and  antiseptic  precautions. 

Porro  operation  and  the  Porro-Muller  modification  are  next  consid- 
ered, and  contrasted  with  the  Cesarean.  Up  to  1885  it  does  not  offer  as 
good  results  to  mother  and  child  as  the  latter. 

"Up  to  March,  1885,  fifty  per  cent,  of  the  mothers  recovered  after  the 
Miiller  modification,  and  forty-four  per  cent,  after  the  unmodified  Porro." 
"There  are,"  the  author  continues,  notwithstanding  this  greater  success  of 
the  Caesarean  operation,  "instances  in  which  the  Porro  or  the  Porro-Muller 
would  seem  to  promise  the  greatest  success.  When,  through  unwarranted 
delay,  or  by  reason  of  unwarranted  attempts  at  delivery  the  uterine  tissues 
have  been  seriously  injured;  or  when  the  child  is  putrid,  or  when  the  patient 
is  greatly  exhausted  with  incipient  or  established  septicaemia,  the  amputation 
of  the  uterus  and  its  appendages  by  the  Miiller  method  would  seem  preferable 
to  the  Caesarean  section;  again,  when  there  is  extensive  fibroid  or  fibro-cystic 
degeneration  of  the  uterine  body,  an  amputation  at  the  neck  would  be  indi- 
cated. Whenever  there  is  especial  reason  to  fear  septicaemia,  the  Miiller  modi- 
fication should  be  preferred  to  the  Caesarean  section  without  amputation." 

It  is  difficult  to  understand  why  in  case  of  septicaemia  Miiller's  method 
should  offer  better  chances  when  we  consider  that  the  chief  cause  of 
death  after  Porro  w^as  from  blood  poisoning,  while  exhaustion  has  been 
the  most  frequent  cause  of  death  after  Csesarean  section. 

Gastro-elytrotomy  is  given  a  short  notice  with  a  valuable  historical 
paragraph.    Dr.  Parvin  says  : 

"  Even  if  the  general  success  of  the  operation  could  be  made  equal  to  that 
which  Skene  has  had,  saving  three  mothers  and  three  children  in  four  opera- 
tions, this  by  no  means  equals  that  which  may  be  hoped  for  from  the  im- 
proved Caesarean  operation.  Moreover,  gastro-elytrotomy  is  impossible  in 
many  cases  in  which  the  other  method  of  delivery  can  be  employed.  Its 
performance  is  liable  to  cause  injury  of  the  bladder,  and  it  is  followed  by 
prolonged  suppuration." 

A  brief  notice  of  the  Csesarean  section  in  post-mortem  delivery  closes 
the  volume. 

We  have  reviewed  the  book  of  one  whom  we  know ;  w^e  know  his 
thorough  conversance  with  his  subject ;  we  know  the  thoughtfulness  of 


MARSH,  DISEASES   OF   THE  JOINTS. 


183 


the  man,  and  we  know  if  he  had  stripped  himself  of  his  allegiance  to 
authority  and  written  from  his  own  ripe  experience,  told  in  the  terse 
and  simple  manner  of  the  book  before  us,  he  would  have  produced  abetter 
book ;  not  better  in  the  sense  of  a  teacher,  but  better  in  the  sense  of 
individuality,  that  pervading  spirit  within  the  covers  of  a  book  that 
makes  it  live  for  itself  and  the  glory  of  its  author.  It  is  one  thing  to  be 
a  teacher;  it  is  another  thing  to  form  opinion  for  those  who  come  after 
us.  One  must  elect  which  he  will  be.  It  is  a  ripe  harvest  that  Dr. 
Parvin  offers  to  his  readers.  We  are  satisfied  with  his  labors,  and  he 
has  done  well.  He  has  elected  to  be  a  teacher  and  as  such  he  has 
followed  in  the  steps  of  those  who  have  gone  before.  He  has  crystallized 
the  thought  that  has  ripened  ;  he  has  been  a  gleaner  but  has  planted  no 
seed  for  the  harvest  of  the  future.  But  the  gleaner  has  his  use  as  well 
as  the  sower  of  seed  and  without  him  there  would  be  an  end  to  all 
progress.  It  has  been  said  that  one  who  invents  a  new  flavor  is  greater 
than  he  who  captures  a  city,  but  how  much  greater  is  one  who  sets  all 
after-coming  men  thinking. 

There  is  no  book  that  can  be  more  safely  recommended  to  the  student 
or  that  can  be  turned  to  in  moments  of  doubt  with  greater  assurance 
of  aid,  as  it  is  a  liberal  digest  of  safe  counsel  that  has  been  patiently 
gathered.  E.  V.  de  W. 


Diseases  of  the  Joints.  By  Howard  Marsh,  F.E.C.S.,  Senior  Assistant 
Surgeon  to,  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital, 
Senior  Surgeon  to  the  Hospital  for  Sick  Children,  and  to  the  Alexandra 
Hospital  for  Hip  Disease.  12mo.  pp.  460.  Philadelphia:  Lea  Brothers  &  Co., 
1886. 

After,  briefly  adverting  to  the  history  of  joint  surgery  and  demon- 
strating how  it  has  fully  kept  pace  with  the  rest  of  the  art,  Mr.  Marsh 
shows  that  this  advance  has  been  chiefly  due  to  the  gradually  increasing 
recognition  of  the  efficiency  of  prolonged  rest  in  staying  the  progress  of 
even  scrofulous  joint  disease,  and  to  the  application  of  the  principles 
of  aseptic  surgery,  which  latterly  "has  produced  results  which  can 
scarcely  be  exaggerated  in  the  management  of  suppuration  in  joint  dis- 
ease. It  is  now  well  known  that  matter,  whether  connected  with  acute 
or  chronic  arthritis,  may  be  safely  evacuated,  with  the  result  that  the 
severe  suffering,  the  prolonged  fever,  the  wide  and  destructive  burrowing, 
and  the  formation  of  sinuses,  which  were  the  common  rule  only  a  few 
years  ago,  can  be  generally  avoided.  These  results  are  more  far  reaching 
than  at  first  sight  they  appear  to  be ;  for  when  disease  can  thus  be 
checked  at  the  outset,  and  when,  should  suppuration  occur,  the  compli- 
cations formerly  so  constantly  met  with  in  connection  with  large  collec- 
tions of  matter  can  be  averted,  diseases  of  the  joints  become  in  their 
whole  aspect  much  less  formidable,  they  extend  over  much  shorter 
periods,  they  lead  to  no  material  deformity,  they  cause  comparatively 
little  suffering,  they  inflict  but  little  injury  on  the  general  health,  while 
such  mutilations  as  excision  and  amputation  are  falling  more  and  more 
into  disuse." 

These  sentences  epitomize  the  author's  theory  and  practice  in  the 
treatment  of  all  forms  of  joint  disease,  with,  of  course,  certain  minor 


184 


REVIEWS. 


details,  which,  when  examined,  prove  only  to  be  modifications — not  con- 
tradictions— of  these  rules.  Admirable  as  rest  is,  beyond  all  question 
as  are  the  advantages  of,  nay  necessities  for  aseptic  surgery,  yet  our  ex- 
perience has  taught  us,  that  with  every  advantage  on  our  side,  there  yet 
remain  more  cases  rebellious  to  perfect  rest  from  their  outset  than  Mr. 
Marsh  is  willing  to  confess. 

We  shall  quote  further  on  some  of  his  extreme  views  as  to  the  possi- 
bilities of  rest  in  all  cases,  if  commenced  as  soon  as  joint  symptoms  ap- 
pear, and  persevered  in  for  years  ;  but  in  passing  we  must  protest  against 
the  teaching — while  fully  believing  in  the  paramount  advantage  of  rest 
— that  only  the  very  rarest  exceptions  to  the  rule  of  cure  will  result,  if 
Mr.  Marsh's  plan  be  pursued,  since  this  is  a  most  dangerous  doctrine 
both  for  patient  and  surgeon:  for  the  former,  siuce  he  loses  faith  and 
unfairly  blames  his  attendant ;  for  the  latter,  because  it  lays  him  open 
to  a  prosecution  for  malpractice. 

Mr.  Marsh  does  not  believe  that  all  strumous  affections  are  tubercu- 
lous because,  apparently,  of  the  absence  of  tubercle  bacilli  in  some  cases, 
ignoring  the  results  obtained  both  experimentally  and  clinically  by 
some  of  the  French  observers  with  these  non-bacillous  cases. 

Again — and  here  most  correctly — he  points  out  that  joint  cases 
which  occur  in  patients  with  strumous  tendencies  are  often  not  sponta- 
neous, but  have  been  lighted  up  by  a  traumatism  without  which  no 
trouble  would  have  occurred,  while  a  mere  chronic  joint  trouble  with 
destructive  tendencies  is  no  proof  whatever  of  struma,  but  is  in  many 
cases  due  to  the  alleged  traumatism  from  which  it  started,  plus  want  of 
proper  treatment  by  rest,  etc.  All  this  we  cordially  endorse.  On  the 
other  hand,  he  also  apparently  believes  that  there  are  a  certain  number 
of  patients  whose  affections  are  solely  due  to  the  deposit  of  tubercular 
products  in  their  osseous  or  articular  tissues. 

Holding  such  views,  excisions  of  joints  and  amputations  of  limbs  for  the 
prevention  of  a  generalized  tuberculosis  are  only  mentioned  to  be  de- 
clared unworthy  of  consideration.  Unlike  so  many  of  our  more  pre- 
tentious works,  this  one  has  been  written  by  a  surgeon  of  ripe  experience 
in  special  fields,  so  that  we  hesitate  to  differ  from  him,  and  yet,  do 
not  modern  theory,  practice,  and  experience  all  teach  very  much  to  the 
contrary  ?  Of  course,  there  are  exceptions ;  but  according  to  our  view 
the  exceptions  are  reversed — i.e.,  what  are  Mr.  Marsh's  exceptions  we 
are  inclined  to  think  rules,  while  his  rules — with  respect  to  struma,  be  it 
understood — we  consider  exceptions.  Perhaps  this  is  too  broadly  stated, 
but  it  approximates  the  truth. 

Mr.  Bowlby  is  credited  with  the  pathological  portion  of  the  work,  his 
descriptions  having  been  adopted  by  Mr.  Marsh.  In  the  main,  the  brief 
descriptions  given  are  good,  but  who  is  responsible  for  the  following  ex- 
traordinary pathological  fact?  "The  bloodvessels  dilate, fresh  capillaries 
are  formed,  the  blood-stream  is  at  first  accelerated,  but  soon  stasis  in 
many  places  ensues  "  (the  italics  are  ours)  !  Nothing  is  more  certain  in 
pathology  than  that  new  bloodvessels  do  not  form  at  the  stage  when  the 
blood-current  is  accelerated,  the  bloodvessels  next  dilating,  and  stasis  is 
only  incipient.  What  the  author  probably  means  is,  that  first  there  is 
either  contraction  followed  by  dilatation,  or  primary  dilatation  of  the 
vessels  with  accelerated  flow,  then  stasis,  then  migration  of  cells,  during 
which  preformed  capillaries  dilate  so  as  to  admit  so  much  red  blood  as  to 
become  distinctly  visible,  and  then,  perhaps,  the  formation  of  new  blood- 


MARSH,  DISEASES  OF  THE  JOINTS. 


185 


vessels  does  take  place,  provided  cell  migration  and  proliferation  advance 
to  the  point  of  forming  false  membranes  or  granulation  tissue.  Equally 
pertinent  criticisms  might  be  made  of  other  pathological  statements. 
We  think  that  either  Mr.  Bowlby  should  have  been  solely  responsible, 
or  that  Mr.  Marsh  should  have  expressed  some  positive  opinion  as  to  his 
own  views,  and  not  have  cautiously  alluded  to  all  the  views  held,  in  the 
compass  of  a  few  lines,  and  then  have  left  the  reader  to  his  conclusions, 
which  must  be  vague  indeed  when  drawn  from  such  premises. 

Speaking  of  acute  synovitis,  the  advice  is  given  to  retain  the  limb  in  the 
position  into  which  the  disease  has  brought  it  by  well-fitting  splints  for 
a  few  days,  after  which,  the  rest  having  removed  the  muscular  rigidity, 
the  limb  will  naturally  subside  into  a  good  position.  We  are  glad — 
while  not  objecting  to  the  operation — to  see  that  the  author  Warns  his 
readers  that  aspiration  of  a  joint  acutely  inflamed  is  not  "  devoid  of 
risk."  Blisters  are  highly  spoken  of  throughout  the  work,  but  no  cau- 
tion is  given  against  their  application  over  superficial  joints.  Thus,  on 
either  side  of  the  patella  between  the  skin  and  synovial  membrane  very 
little  tissue  exists,  and  counter-irritation  is  too  often  a  misnomer,  since 
epispastics,  especially  if  allowed  to  remain  too  long,  directly  irritate  the 
synovial  membrane.  Irritation  of  the  vascular  areas  above  and  below  a 
superficial  joint  is  the  better  practice,  while  even  the  formation  of  an 
eschar  may  be  beneficial  over  a  deep-seated  joint,  as  the  hip  :  this  is  our 
practice,  and  general  experience  has  demonstrated  its  value. 

The  general  impression  of  the  hopelessness  of  saving  a  movable  joint 
or  even  life  when  acute  suppurative  arthritis  of  a  large  joint  occurs  is 
combated,  and  we  are  glad  to  see  that  the  author  has  proved  by  results 
what  we  have  ourselves  demonstrated,  that  free  incisions,  drainage,  and 
aseptic  dressings  will  often  save  life  and  at  times  a  useful  joint. 

The  section  on  gout  should  be  most  carefully  read  by  the  American 
practitioner,  who,  in  general,  seems  to  be  possessed  by  two  erroneous 
impressions,  viz.,  that  gout  affects  only  the  smaller  joints  in  a  first  attack  ; 
that  nothing  but  port  wine  and  high  living  can  produce  gout ;  and  that, 
in  consequence,  the  disease  must  be  very  rare  here,  ignoring  the  fact  that 
malt  liquors  in  large  quantity  in  those  who  use  but  little  exercise  will 
develop  the  disease  de  novo,  all  the  more  so  if  there  be  hereditary 
taint.  We  frequently  see  the  evil  effects  of  this  wilful  blindness  as  to 
the  prevalence  of  latent  and  at  times  frank  gout  in  this  country. 

Again,  in  rheumatic  fever,  should  suppuration  occur,  at  once  the  prac- 
titioner thinks  he  has  made  a  mistake  and  that  the  disease  was  pyaemia 
all  along.  This  may  be  the  true  explanation,  but  when  only  one  joint 
suppurates  the  original  diagnosis  is  probably  correct.  Rheumatic  joints 
are  also  too  commonly  considered  so  safe  against  displacement  as  to  be 
unworthy  of  any  special  care,  but  Mr.  Marsh  avers  that  in  the  knee, 
wrist,  and  ankle,  there  is  decided  risk  of  displacement  and  deforniity 
when  the  disease  is  persistent. 

In  an  excellent  chapter  on  so-called  "  Osteo-arthritis,"  the  author 
shows  by  a  series  of  brief  but  admirable  pen  sketches,  that  the  condition 
called  by  former  authors  rheumatic  gout,  chronic  rheumatic  arthritis, 
arthritis  deformans,  etc.,  and  now  termed  osteo-arthritis,  is  not  a  unity 
but  a  number  of  differing  diseases  which  merely  present  certain 
resemblances  as  the  ultimate  result  of  their  morbid  processes.  Mr. 
Marsh  uses  the  term  osteo-arthritis  as  a  convenient  general  heading  for 
a  group  of  diseases  characterized  by  a  generally  chronic,  steadily  pro- 


186 


REVIEWS. 


gressing,  painful  stiffening,  enlargement  and  distortion  of  the  joints,  with 
destruction  of  the  cartilages,  ligaments,  and  surrounding  tendons,  osteo- 
phyte formations  at  the  articular  edges  and  sometimes  in  the  remains  of 
neighboring  tendons.  Pathologically  consisting  of  no  less  than  seven 
different  groups,  in  general  terms  it  is  either  purely  a  degenerative  change, 
"  or  a  degenerative  process  to  which  a  variable  but  limited  degree  of 
inflammatory  action  is  superadded."  Although  generally  chronic,  there 
is  an  acute  form  which  closely  simulates  acute  rheumatism,  although 
without  the  profuse  sweatings  and  tendency  to  acute  endo-  and  pericar- 
ditis, but  which  may  in  a  few  weeks  seriously  damage  many  joints.  In 
addition,  there  is  another  rare  form  which  attacks  young  subjects — even 
so  young  as  two  and  a  half  years.  As  there  are  in  reality  so  many 
different  diseases  grouped  under  this  one  head,  so  is  the  treatment  various  ; 
but  for  details  we  must  refer  the  reader  to  the  original.  Hydrarthrosis 
is  looked  upon  as  probably  the  result  of  ill-marked  osteo-arthritis,  and 
the  important  fact  is  emphasized  that  when  bursal  enlargement  occurs  in 
connection  with  hydrarthrosis,  the  bursal  sacs  commonly  open  into  the 
joint  cavity. 

From  an  extended  but  excellent  chapter  on  "  Charcot's  Disease,"  we 
shall  quote  but  one  sentence :  "  It  is  certainly  necessary,  without  falling 
into  the  absurdity  of  finding  Charcot's  disease  in  every  case  of  osteo- 
arthritis, to  be  on  the  watch  in  obscure  examples  of  disease  attacking 
a  single  joint,  especially  if  the  articulation  is  free  from  pain,  although 
the  seat  of  advancing  deformity,  for  the  occurrence  of  ataxic  symptoms." 

The  author's  views  concerning  scrofulous  diseases  have  been  already 
referred  to  and  it  now  only  remains  to  quote  a  few  sentences.  "  The 
estimate  of  their  gravity  is  often  formed  partly  from  tradition,  partly 
from  what  is  seen  in  the  wards  and  out-patient  rooms  of  hospitals,  where 
every  day  children  are  admitted  whose  joints  have  undergone  complete 
disorganization."  .  .  .  "Such  cases  as  these,  however,  convey  a  highly 
exaggerated  impression  of  the  intractable  nature  of  these  affections.  It 
must  be  remembered  that  a  disease  of  inflammatory  character  is  very 
much  what  it  is  allowed  to  become."  ...  "In  their  incipient  period 
these  affections  are,  to  a  degree  which  some  appear  unable  to  credit, 
amenable  to  the  influence  of  appropriate  treatment."  .  .  .  "  The  presence 
of  amyloid  disease  in  its  early  stage  is  no  bar  to  operative  interference, 
even  although  the  urine  may  contain  a  considerable  amount  of  albumen." 
Rest,  prolonged  for  years  if  necessary  and — until  the  very  last — in  the 
horizontal  posture,  is  the  treatment  advocated,  there  being  no  risk,  so 
maintains  Mr.  Marsh,  that  the  joint  will  be  rendered  stiff  by  the  rest 
alone.    As  to  this  latter  point  we  are  in  perfect  accord  with  the  author. 

"  Epiphysitis  and  Acute  Arthritis  of  Infants  "  form  the  subjects  for 
an  interesting  and  instructive  chapter.  "  Quiet  Disease  "  is  next  treated 
of,  wherein  it  is  stated  that  instances  "  are  not  rarely  seen  in  children 
between  four  and  twelve,  in  whom  the  shoulder-joint  is  found  to  have 
become  stiff,  though  none  of  the  other  signs  of  disease  have  been 
observed."  So  with  other  joints.  These  cases  are  apt  to  be  confounded, 
in  their  early  stages,  with  cases  of  muscular  rigidity  following  injury, 
all  the  more  so  because  at  first  under  an  anaesthetic  the  joint  moves  freely 
and  smoothly.  "In  the  hip  all  the  usual  symptoms,  except  stiffness, 
may  be  so  entirely  absent  that  for  many  months  no  suspicion  of  the  real 
state  of  the  case  is  excited." 

Complete  rest  for  months  is  the  only  treatment,  and  in  many  cases  the 


MARSH,  DISEASES  OF   THE  JOINTS. 


187 


joints  will  ultimately  recover  with  good  motion.  In  some  cases,  however, 
rapid  ankylosis  sets  in,  and  these  are  the  cases  which  have  given  rise  to 
the  idea  that  joints  kept  at  rest  become  ankylosed,  but  this  is  the  marked 
exception  even  in  "  Quiet  Disease."  Syphilitic  diseases  of  joints,  the 
joints  in  haemophilia,  diseases  of  bursse,  and  the  formation  of  cysts  in 
connection  with  the  joints,  are  all  sufficiently  fully  treated  of.  Loose 
bodies  in  joints  are  elaborately  discussed  and  operative  interference  with 
antiseptic  precautions  is  advised,  with  the  pertinent  remark  "  that  the 
statistics  of  fifty  years  ago  have  no  bearing  whatever  on  the  practice  of 
the  present  day." 

Internal  derangement  of  the  knee  and  other  joints  is  shown  to  be  far 
more  frequent  than  is  commonly  supposed.  When  dealing  with  a  case 
where  the  injury  which  has  produced  the  displacement  is  severe  enough 
to  cause  also  acute  synovitis,  or  where  the  displacement  has  produced 
the  latter  complication,  caution  is  requisite  lest  the  luxation  of  the  carti- 
lage be  overlooked,  and  the  stiffness  remaining  after  the  inflammation 
has  subsided  be  attributed  to  this  cause.  Where  the  slipping  of  the 
cartilage  becomes  inveterate  two  varieties  of  clamps  are  figured  which 
are  notably  efficient,  but  do  not  interfere  with  walking.  Reference  is 
made  to  Prof.  Kocher's  description  of  what  he  terms  meniscitis  fungosa, 
or  fungous  enlargement  of  the  internal  meniscus  of  the  knee-joint ; 
removal  by  operation  is  all  that  is  available  in  such  cases.  Much  interest- 
ing matter  is  contained  in  the  chapters  on  "  Bone-setting,"  and  "  Con- 
genital Dislocation  of  the  Hip,"  but  no  comments  will  be  made  except 
the  statement  that  the  author  seems  to  show  conclusively  that  slight 
varieties  of  congenital  hip  luxation  often  exist  which  are  either  over- 
looked or  mistaken  for  some  other  trouble. 

An  able  chapter  is  devoted  to  the  "  Prejudicial  Effects  of  Intra-articular 
Pressure  and  on  the  Danger  of  Producing  it  by  Surgical  Appliances." 
It  will  perhaps  be  difficult  for  the  reviewer  to  make  plain  that  which 
the  author  demonstrates  so  well  by  means  of  a  few  diagrams,  but  the 
subject  is  of  too  much  importance  to  be  passed  over.  The  author  con- 
clusively demonstrates,  that  while  extension  by  weight  and  pulley  in  a 
perfectly  extended  hip  or  knee  will  remove  intra-articular  pressure,  yet 
if  the  leg  be  flexed  upon  the  thigh  or  the  thigh  upon  the  pelvis,  by  the 
spasmodically  contracted  hamstring  muscles  in  the  former  and  the  ilio- 
psoas muscle  in  the  latter,  these  structures  at  once  become  fulcra  and 
the  articular  surfaces  are  brought  into  abnormally  close  contact  by 
leverage  of  the  second  order.  For  this  reason  extension  should,  at  first, 
be  always  made  in  the  direction  of  deformity,  and  gradually,  in  the  course 
of  a  few  weeks,  the  line  of  traction  may  be  changed  as  the  irritated 
muscles  relax,  until  the  knee  or  hip  is  perfectly  extended.  The  prac- 
titioner would  do  well  to  consult  this  chapter,  which,  to  our  mind,  seems 
the  one  most  pregnant  with  good  results. 

The  chapters  on  nervous  mimicry  and  tumors  of  joints,  while  up  to  the 
average,  demand  no  special  notice. 

In  fibrous  ankylosis  after  strumous  disease  emphatic  warning  is  given 
against  the  attempt  to  restore  movement,  a  most  fatal  error,  which  we 
think  must  have  now  fallen  into  almost  total  disuse,  since  it  has  been 
almost  universally  discountenanced  of  late  years.  Two  omissions  we 
regret  to  see  in  the  advice  concerning  breaking  of  fibrous  ankylosis,  viz., 
the  advisability  of  perfect  quiet  for  a  few  days,  the  immediate  applica- 
tion of  an  elastic  bandage,  or  elastic  pressure  by  compressed  sponge,  and 


188 


REVIEWS. 


the  use  of  dry  cold  when  the  operation  is  a  severe  one,  for  in  this  way 
much  can  be  done  with  perfect  safety  and  much  utility ;  and  that  dis- 
location of  the  head  of  the  tibia  backward  may  be  partly  or  entirely 
prevented,  when  attempting  to  straighten  a  contracted  knee  by  subcu- 
taneous division  with  a  tenotome  of  the  anterior,  or  even  both  crucial 
ligaments,  a  practice — following  the  lead  of  a  well-known  surgeon — 
which  we  have  long  advocated  and  seen  prove  successful :  the  patella 
may  likewise  be  dissected  off  subcutaneously  when  adherent.  Of  course, 
strict  antiseptic  precautions  must  be  exercised. 

Mr.  Marsh  contends  that  we  must  entirely  revise  our  ideas  as  to  ex- 
cision for  strumous  disease,  that  the  statistics  of  even  ten  years  back  are 
in  many  instances  obsolete,  that  excision  is  now  comparatively  not 
dangerous,  that  strumous  disease  both  by  conservative  and  operative 
treatment  has  alike  only  about  ten  per  cent,  of  mortality,  allowing  the 
widest  margin ;  that  "  excision  under  favorable  conditions  can  be,  and 
had  better  be,  avoided  ;  "  that  "  recovery  will,  as  a  rule,  except  in  very 
advanced  disease,  be  secured  by  rest ;  "  and,  finally,  he  believes  "  that  in 
the  future  excision  will  fall  more  and  more  into  disuse,  as  the  treatment 
by  rest  gradually  wins  its  way."  While  by  no  means  a  pessimist,  we 
can  hardly  feel  justified  in  indulging  in  such  roseate  visions,  when  we 
reflect  upon  the  perversity  and  unwillingness  to  submit  to  restraint  for 
lengthened  periods  shown  by  the  average  patient  or  parent. 

Excision  of  the  shoulder  is  said  to  be,  "  on  the  whole,  deservedly  un- 
popular," an  opinion  from  which  we  most  positively  dissent.  In  excising 
the  elbow,  to  gain  a  flexible  joint,  the  rule  is  given  that  the  ends  of  the 
bones  should  present  an  interval  between  them  of  at  least  half  an  inch 
when  put  up  in  the  splints.  Excisions  of  the  other  joints  are  viewed 
very  unfavorably,  being  really  advised  only  for  the  removal  of  deformity 
in  the  case  of  the  knee,  or  for  deformity  plus  extensive  suppuration  in 
the  hip.  Diseases  of  the  different  articulations  are  elaborately,  and  we 
think  well  treated  of  in  the  remainder  of  the  book,  but  from  what  has 
already  been  said  little  remains  for  us  to  call  the  attention  of  our  readers 
to,  since  the  details  differ  in  no  material  respects  from  those  of  other 
standard  works. 

We  wish  that  experience  in  our  own  practice  or  in  that  of  our  friends 
could  induce  us  to  agree  with  Mr.  Marsh  in  his  favorable  views  as  to 
the  mortality  and  after-condition  of  cases  of  strumous  knee  and  hip 
disease.  Thus,  in  the  knee,  recovery  may  "  be  confidently  anticipated 
except  in  a  few  cases  in  which  the  disease  proves  to  be  more  than  com- 
monly destructive."  For  the  hip,  he  says  :  "  In  cases  that  are  detected 
early  and  adequately  treated  perfect  recovery,  with  complete  restoration 
of  movement,  may  often  be  obtained.  In  many  others  the  only  appre- 
ciable defect  is  a  slight  limp,  due  either  to  loss  of  free  movement,  to 
reflex  atrophy  of  the  muscles,  or  to  slightly  arrested  growth  of  the 
limb.  Even  in  instances  in  which  disease  has  produced  faulty  position 
and  suppuration,  the  treatment  by  rest  continued  for  a  year  or  for  a 
still  longer  period,  and  combined  with  extension  to  correct  distortion, 
and  with  the  early  evacuation  of  pus  will  often  enable  children  to  re- 
cover without  deformity,  with  almost  perfect  movement  in  the  joint,  and 
with  scarcely  a  limp."  Surely  this  is  a  most  exaggerated  statement  of 
the  facts. 

Although  we  have  seen  fit  to  differ  from  Mr.  Marsh  both  on  theoret- 
ical and  practical  grounds  in  some  few  instances,  yet  we  regard  the 


WORKS  ON   THE   TREATMENT   OF   THE  INSANE. 


189 


book  as  excellent,  and  one  the  writing  of  which  will  redound  to  the 
credit  of  the  author.  This,  like  all  the  other  clinical  manuals  issued 
by  this  firm,  possesses  one  preeminent  advantage,  viz.,  that,  however  much 
the  views  of  the  authors  may  differ  from  those  we,  or  others,  hold,  the 
opinions  are  enunciated  by  those  who  have  been  taught  by  extensive 
experience,  and  not  by  ambitious  writers,  who,  desirous  of  the  name 
author,  are  too  often  evidently  first  becoming  acquainted  with  their 
subject  when  studying  the  literature  relating  to  it.  C.  B.  N. 


Kecent  Works  on  the  Treatment  of  the  Insane. 

1.  The  Curability  of  Insanity:  A  Series  of  Studies.  By  Pliny 
Earle,  A.M.,  M.D.,  Late  Superintendent  of  the  State  Lunatic  Hospital, 
at  Northampton,  Massachusetts,  etc.  8vo.  pp.  232.  Philadelphia:  J.  B. 
Lippincott  Company,  1887. 

2.  The  Private  Treatment  of  the  Insane  as  Single  Patients.  By 
Edward  East,  M.R.C  S.,  L.S.A.,  Member  of  the  Medico-Psychological 
Association.    12mo.  pp.  68.    London :  J.  &  A.  Churchill,  1886. 

3.  Insanity  and  Allied  Neuroses:  Practical  and  Clinical.  By 
George  H.  Savage,  M.D.,  M.R.C. P.,  Physician  and  Superintendent  of 
Bethlem  Royal  Hospital,  etc.  12mo.  pp.  viii.  544,  with  19  illustrations. 
Philadelphia :  Henry  C.  Lea's  Son  &  Co.,  1884. 

1.  Dr.  Earle,  one  of  two  survivors  of  thirteen  physicians  who  founded 
the  Association  of  Superintendents  of  American  Institutions  for  the  In- 
sane, has  presented  in  this  volume  a  series  of  "studies  "  on  the  curability 
of  insanity.  Connected  as  he  has  been  as  a  medical  officer  with  one 
asylum,  as  a  medical  superintendent  of  two  asylums  and  with  the  litera- 
ture of  insanity  for  a  period  of  more  than  forty  years,  whatever  he  may 
state  at  the  close  of  a  long,  and  honorable  service  is  entitled  to  respectful 
consideration.  The  purpose  of  the  author  is  to  correct  erroneous  im- 
pressions that  might  be  drawn  from  the  earlier  reports  of  American 
asylums  of  the  curability  of  insanity,  and  to  ascertain  the  results  which 
more  extended  experience  has  since  established.  In  this  direction  the 
author  may  be  said  to  have  done  an  excellent  work,  and  to  have  pre- 
sented a  successful  and  exhaustive  arraignment  and  impeachment  of 
earlier  reported  asylum  results. 

The  book  comprises  eight  so-called  "studies,"  which  have  been  read 
before  the  New  England  Psychological  Society,  or  have  appeared  in  the 
annual  reports  of  the  Northampton  (Mass.)  Hospital.  "They  have  thus 
been  an  important  agent  in  stimulating  the  minds  of  philanthropists  to 
seek — and  in  several  notable  instances  to  adopt — other  methods  for  the 
custody  and  care  of  a  large  part  of  the  insane  than  that  of  collecting 
them  in  expensive  and  unwieldy  curative  institutions." 

In  1820,  Dr.  Burrows,  of  England,  reported  the  proportion  of  re- 
coveries of  all  cases  treated  by  him,  81  in  100;  of  recent  cases,  1>1  in  LOO. 
In  1826-27,  Dr.  Todd,  of  the  Retreat,  Hartford,  reported  that  of  twenty- 
eight  recent  cases  twenty-five  recovered,  equal  to  eighty-nine  per  com. 


190 


REVIEWS. 


Dr.  Woodward,  of  the  Worcester,  Massachusetts,  Asylum,  says  in  1837, 
"per  cent,  of  recent  cases  discharged  recovered,  of  less  duration  than  one 
year,  eighty-nine,  and  in  his  report  in  1841,  ninety  one  per  cent,  re- 
covered." Dr.  Gait,  of  Virginia,  reported  in  1842  an  equal  result,  and 
that  the  West  might  not  be  outdone,  or  charged  with  doing  its  scientific 
work  on  a  contracted  scale,  Dr.  Awl,  of  Ohio,  in  1843,  "unpretentiously 
reported"  his  achievements  of  one  year,  as  follows:  "per  cent,  of  re- 
coveries on  all  recent  cases  discharged,  one  hundred."  Dr.  Earle  in  a 
report  of  the  Bloomingdale  Asylum  for  1844,  states  that  "when  the 
proper  remedial  measures  are  adopted  in  the  early  stages  of  the  disorder, 
no  less  than  eighty  of  every  hundred  are  cured." 

Since  the  "  summit  of  the  maximum  wave  of  the  highest  possible  high- 
water  point  was  gained"  in  the  record  of  cures,  there  has  been  a  steady 
decline  of  the  per  cent,  of  reported  recoveries.  Dr.  Earle  devotes  a 
chapter  to  the  "ebbing  tide"  to  explain  in  part  the  sources  of  error  in 
the  early  hospital  reports  in  this  and  other  countries,  and  to  present 
some  conclusions  as  to  the  curability  of  insanity.    It  is  shown : 

"1.  The  reported  recoveries  from  insanity  are  increased  to  an  important 
extent  by  repeated  recoveries  from  the  periodic  or  recurrent  form  of  the  dis- 
ease in  the  same  person;  and  consequently, 

"  2.  The  recoveries  of  persons  are  much  less  numerous  than  the  recoveries  of 
patients  or  cases ;  and,  consequently, 

"3.  From  the  number  of  reported  recoveries  of  cases  or  patients,  it  is  generally 
impossible  to  ascertain  the  number  of  persons  who  recovered. 

"  4.  The  large  proportion  of  recoveries  formerly  reported  was  often  based  on 
the  number  of  patients  discharged,  instead  of  the  number  admitted,  and  gener- 
ally, upon  the  results  in  a  number  of  cases  too  small  to  entitle  the  deduction 
therefrom  of  a  general  formula  of  scientific  truth;  and  those  proportions  wrere 
evidently  increased  by  that  zeal  and  rivalry  whioh  frequently  characterize  the 
earlier  periods  of  a  great  philanthropic  enterprise." 

To  illustrate,  the  data  from  which  Dr.  Earle  has  drawn  his  deductions 
are  furnished  from  an  analysis  of  the  operations  of  the  Friends'  Asylum, 
by  Dr.  Worthington,  and  reports  of  other  asylums.  One  thousand  and 
sixty-one  recent  cases  were  admitted  into  the  Friends'  Asylum  during  a 
period  of  fifty-nine  years  of  which  sixty-five  per  cent,  recovered,  but 
these  cases  were  not  persons  and  eighty-seven  of  the  persons  recovered 
two  hundred  and  seventy-five  times,  or  one  hundred  and  eighty-seven 
times  more  than  the  number  of  persons.  At  the  Hartford  Ketreat  five 
persons  furnished  fifty-four  recoveries ;  at  the  Bloomingdale  Asylum  five 
persons  furnished  eighty-five  recoveries ;  at  the  Worcester  Hospital  two 
sex  groups  of  five  each  one  hundred  and  thirty-six  recoveries ;  and  in 
one  other  hospital  one  person  furnished  thirty-four  recoveries.  While 
these  are  probably  extreme  illustrations,  it  appears  on  examination  that 
of  11,000  cases  admitted  into  the  Worcester  Hospital,  the  number  of 
persons  was  only  8204,  and  a  similar  result  might  probably  be  shown  in 
the  statistics  of  other  hospitals. 

Turning  to  a  later  period,  the  author,  in  the  concluding  chapter,  pro- 
poses to  show  the  results  of  treatment  in  a  large  number  of  foreign  and 
domestic  institutions,  bringing  our  knowledge  to  a  recent  date,  and  pre- 
sents what  may  be  considered  the  hospital  work  accomplished  at  the 
present  day.  For  this  purpose  he  uses  the  statistics  of  forty-six  English 
and  Scotch  asylums  from  1872  to  1882  inclusive,  published  by  T.  P. 
Chapman,  England,  in  the  Journal  of  Mental  Science  for  July,  1884.  The 


WORKS   ON   THE   TREATMENT  OF   THE  INSANE. 


191 


collection  embraces  93,543  cases,  of  which  35,468,  or  37.9  per  cent,  of 
the  whole  number  of  admissions,  recovered. 

Considered  with  reference  to  the  duration  of  less  than  one  year  69,983 
cases  are  classified  as  follows : 

First  attack,  less  than  three  months,         88,283        Kecoveries,  18,654         Percent.  48.72 
"       "      three  to  twelve  months,         12,126  "  3,421  "  28.21 

Not  first  attack,  less  than  twelve  months,  19,574  "         10,494  "  53.61 


Totals,  69,983  32,569 


The  American  result  is  ascertained  by  taking  the  recoveries  reported 
at  twenty  hospitals  at  three  periods  of  their  existence,  viz.,  the  first  five 
year  period  dating  from  the  opening  of  the  asylum ;  the  second  five 
year  period  begins  with  1871 ;  and  the  third  period  of  five  years  begins 
with  1880. 


Aggregate  admissions  first  period,     14,516  Recoveries,  6,689  Per  cent.,  46.08 

"                "       second  period,  24,383                  "  8,354  "  34.26 

"               "      third  period,    23,052                 "  6,896  "  29.91 

Whole  numher,          61,951                 "  21,939  "  36.71 

At  fifty-eight  American  institutions  the  whole  number  of  patients  ad- 
mitted in  one  year,  1884,  was  14,372,  of  which  27.88  per  cent,  recovered. 

Dr.  Earle  has  done  a  good  work  in  his  successful  effort  to  point  out 
sources  of  error  in  the  statistics  of  insanity  which  appear  to  have  had 
their  origin  in  the  New  England  States,  and  with  his  early  contempora- 
ries. For  more  than  twenty  years,  however,  they  have  been  recognized 
and  avoided  by  the  leading  hospitals  of  the  country.  While  the  per  cent, 
of  reported  recoveries  has  been  steadily  declining,  the  fact  might  have 
been  properly  ascribed  to  a  limited  knowledge  of  the  nature  of  insanity 
that  existed  at  an  earlier  day ;  to  preference  in  admission  given  to  recent 
cases  and  exclusion  of  chronic  cases ;  to  the  increased  number  of  hos- 
pitals at  the  present  day,  and  the  distribution  of  the  limited  number  of 
recent  cases  among  a  larger  number  of  asylums  ;  the  retention  of  chronic 
cases  in  the  asylums  to  a  greater  extent  than  ever  before,  and  not  to  a 
decline  in  the  means  or  skill  in  the  treatment  of  the  insane.  As  a 
matter  of  fact,  never  in  the  history  of  the  care  of  the  insane  were  they 
treated  in  a  more  enlightened  and  humane  manner,  or  with  more  knowl- 
edge and  intelligence.  We  may  go  even  further  and.  express  the  con- 
viction that  recent  cases  of  the  present  day  are  more  successfully  treated 
than  at  any  previous  period.  A  perusal  of  the  book  may  tend  to  a 
pessimistic  view  of  the  whole  subject,  yet  such  an  impression  was  hardly 
intended  to  be  conveyed  by  the  author.  We  must  accept  his  purpose 
to  furnish  an  argument  sustained  by  statistics  which  he  believes  has 
already  "caused  a  very  important  change  in  the  statistical  methods  of 
Massachusetts,  in  this  country,  Great  Britain,  and  in  Europe." 

2.  Mr.  East  assumes  that  treatment  in  the  patient's  own  home  will  be 
first  attempted,  "  but,  as  a  rule,  will  fail  because  of  the  many  familiar 
ways  and  habits  of  the  home,  where  the  patient  has  been  accustomed  to 
command,  and  to  do  as  he  pleases,"  and  concedes  that  if  the  patient  is 
not  so  ill  as  to  be  confined  to  one  room  it  is  generally  best  to  intrust 
him  to  the  care  of  a  medical  man  in  a  house  with  trained  attendants 
selected  by  him,  which  is  to  be  understood  as  the  author's  plan  for  the 
private  treatment  of  the  insane. 


192 


REVIEWS. 


Several  reasons  are  furnished  for  preferring  the  private  method  of 
treating  cases  of  unsound  mind : 

"  First,  greater  secrecy  ;  second,  the  stigma  of  having  been  an  inmate  of  an 
asylum  is  obviated  ;  thirdly,  patients  recover  quite  as  satisfactorily  and  more 
quickly  if  not  compelled  to  mix  with  others  similarly  afflicted ;  fourthly,  the 
exercise  of  a  little  care  will,  in  many  instances,  insure  the  return  of  the 
patient  to  his  home  without  any  of  his  acquaintances  becoming  aware  of  the 
reasons  that  have  led  to  his  absence ;  fifthly,  that  each  case  receives  more  in- 
dividual attention  at  the  hands  of  the  medical  man  and  attendants  employed, 
and  there  is  a  better  chance  of  his  getting  the  exact  treatment  suitable  to  his 
case,  a  practical  impossibility  in  an  institution  numbering  its  patients  by 
hundreds." 

If  for  any  reason  the  patient  is  not  a  suitable  case  for  private  treat- 
ment, the  author  prefers  an  excellent  hospital  for  the  insane  to  a  private 
asylum. 

Strangely  enough,  none  of  the  reasons  presented  seem  to  have  been 
founded  on  the  results  of  professional  experience  definitely  ascertained. 
They  are  rather  a  concession  and  deference  to  the  private  feelings  and 
interests  of  the  friends  of  patients  which  naturally  exist,  and  to  ill- 
founded  traditional  prejudice  against  established  hospitals  prevalent  in 
the  public  mind.  The  chapters  devoted  to  "Selection  of  Attendants," 
"Treatment,"  and  "Tact,"  contain  no  suggestions  which  are  not,  or  may 
not  be,  as  well  or  better  carried  out  in  organized  hospitals  with  a  larger 
plant  and  resources,  than  any  system  of  private  treatment  can  afford. 
If,  as  is  alleged,  the  insane  person  may  awaken  to  reason  and  be  shocked 
to  find  himself  surrounded  by  the  insane  in  a  hospital,  so- it  may  be  sup- 
posed he  may  awaken  to  find  himself  in  a  strange  house  surrounded  by 
strangers,  a  close  prisoner  perhaps  without  the  warrant  or  sanction  of 
law.  Both  of  these  supposed  awakenings  may,  however,  be  regarded  as 
extremely  hypothetical,  as  all  experience  shows  that  changes  are  usually 
gradual  and  not  sudden. 

The  detention  of  insane  persons,  singly,  in  private  houses  is  a  respon- 
sibility that  may  be  intrusted  to  a  very  limited  number  of  persons  without 
risk  of  abuse.  Yet  experience  has  shown  that  it  is  wiser  and  safer  for 
all  concerned  that  single,  private  care  of  the  insane  in  houses,  other 
than  in  their  own  homes,  should  have  the  sanction  of  law  and  the  super- 
vision of  State  officers.  Of  the  results  of  private  treatment  of  the  insane 
the  author  has  made  no  statement  from  which  its  value  may  be  esti- 
mated. In  the  last  report  of  the  English  Commissioners  of  Lunacy 
may  be  found  the  proportion  of  per  cent,  of  recoveries  to  admissions  for 
the  year,  which  is  presented  in  this  connection : 

County  asylums   42.26      Registered  hospitals     ....  45.56 

Metropolitan  licensed  houses      .      .    39.07      Provincial  licensed  hospitals      .       .  36.48 
Private  single  patients       .      .  .10.83 

The  book  has  no  special  suggestions  or  advantages  to  offer  for  the 
benefit  of  the  insane  of  the  indigent  or  middle  class,  but  is  in  the  line 
of  improved  care  of  the  insane  of  the  private  class  who  are  able  and 
willing  to  pay  a  large  weekly  charge.  It  is  also  to  be  accepted  as  a  mild 
protest  against  some  of  the  acknowledged  defects  of  the  existing  hos- 
pital system  which  time  and  improved  plans  will  correct.       J.  B.  C. 

3.  The  name  Bedlam  is  so  inseparably  connected  with,  and  made  a 
part  of  the  history*  of  the  treatment  of  the  insane,  and  so  much  that  has 


WORKS  ON   THE   TREATMENT   OF   THE   INSANE.  193 


redounded  to  the  credit  of  England's  lunacy  administration  received  its 
birth  and  impetus  in  the  revelation  of  the  practices  of  old  Bedlam,  that 
it  seems  eminently  fitting  that  from  modern  Bethlem  a  clinical  text- 
book should  be  evolved,  replete  with  ideas  and  suggestions  for  the  better 
care  and  treatment  of  the  insane.  As  one  of  the  editors  of  the  Journal 
of  Mental  Science,  the  organ  of  the  British  alienists,  Dr.  Savage  has  for 
a  long  time  been  known  as  a  man  of  progressive  ideas ;  but  it  is,  per- 
haps, as  a  clinical  teacher  at  Guy's,  and  in  the  wards  of  his  own  hospital, 
that  his  work  has  been  most  effective,  if  not  the  most  widely  known. 

The  work  under  consideration  is  the  result  of  an  attempt  to  "  take 
stock "  of  a  mass  of  observations  and  deductions  accumulated  during 
the  experience  of  twelve  years  as  a  superintendent  of  a  hospital  for  the 
insane,  and  a  lecturer  on  insanity,  and,  as  would  be  expected,  is  of  a 
very  practical  nature. 

Dr.  Savage  is  met  at  the  outset  by  the  same  difficulty  which  all  writers 
upon  mental  disorders  have  encountered,  when  he  attempts  to  define 
insanity.  From  a  medical  standpoint,  he  says  it  is  to  be  considered  "  a 
disease  of  the  brain."  Would  not  it  be  more  in  accordance  with  the 
facts  to  say  a  symptom  of  a  disease  of  the  brain  ?  To  borrow  from  the 
author's  own  words,  "sanity"  and  "insanity"  are  words  which  we  use 
to  designate  certain  conditions,  neither  of  which  can  be  rigidly  confined 
within  the  bounds  of  a  definition,  and  as  we  regard  sanity  as  the  condi- 
tion resulting  from  the  normal  action  of  a  healthy  brain,  so  we  must 
consider  insanity  as  the  symptom  of  a  diseased  brain,  and  not  as  the  dis- 
ease.   Dr.  Savage  says,  in  discussing  this  point : 

"A  man  in  fact  must  be  considered  as  sane,  or  insane,  in  relation  to  himself. 
The  old,  and  oft- repeated  statement  that  insanity  is  a  perversion  of  the  ego,  is 
absolutely  true.  Sanity  and  insanity,  then,  are  to  be  measured  by  differences 
or  changes  of  habit,  taste,  and  disposition  in  the  individual,  as  well  as  by 
other  symptoms  of  change  in  the  nervous  centres.  The  difference  will  neces- 
sarily be  seen  to  be  not  only  one  of  degree,  but  one.  of  time,  so  that  a  man 
being  sane  now  may  be  insane  within  a  longer  or  shorter  period.  I  shall  take 
it  for  granted  that  insanity  depends  upon  change  in  the  nervous  structures  of 
the  body  ;  but  by  no  means  shall  I  restrict  the  causation  of  insanity  to  changes 
in  the  brain  alone  But  the  more  I  see  of  insanity  the  more  con- 
vinced I  am  that  the  consideration  of  mental  disorder  can  only  be  fairly 
approached  by  the  complete  consideration  of  general  physiology — i.  e.,  the 
development,  growth,  and  decay  of  the  body  in  all  its  parts." 

The  subjects  of  eccentricity  and  genius  are  touched  upon,  incidental 
to  the  general  subject  of  insanity.  Eccentric  people  are  divided  into  two 
classes:  1.  Those  having  a  neurotic  inheritance,  and  who  are,  in  fact, 
on  the  border-land  of  insanity,  and  2.  Cases  developed  de  novo,  who  pass 
through  life  without  any  marked  access  of  mental  disturbance.  The 
classification  adopted  by  Dr.  Savage  shows  at  once  that  he  approaches 
the  subject  from  a  clinical  standpoint,  and  that  he  does  not  propose  to 
lumber  up  his  work  or  confuse  his  readers  with  the  fine  and  unnecessary 
divisions  and  subdivisions  so  much  affected  by  dilettante  writers. 

From  our  present  knowledge  of  insanity  and  the  pathological  pro- 
cesses which  lead  up  to  it,  it  necessarily  arises  that  any  scheme  of 
classification  must  be  imperfect,  and  that  various  forms  of  mental 
disturbance  will  be  found  to  belong — in  some  respects  to  one,  in  some 
respects  to  another  division  of  the  classification.  In  certain  case's  the 
etiological  factors  are  so  prominent  that  they  are  instinctively  classified 

NO.  CLXXXVII. — JULY,  1887.  13 


19-1 


KEVIEWS. 


according  to  their  causes.  In  some  symptomatic,  and  in  others  somatic 
features  predominate,  and  until  the  time  arrives  when  we  shall  have  a 
clear  knowledge  of  the  pathology  of  insanity  we  must  despair  of  a  per- 
fect classification.  When  that  time  arrives,  if  it  ever  does,  then  even 
we  shall  be  met  by  the  difficulty  resulting  from  the  fact  that  similar 
mental  states  may  be  caused  by  the  same  apparent  condition  of  nerve 
disease  or  degeneration. 

Dr.  Savage  groups  his  cases  as  follows  : 

"  Hysteria — mania.    Hypochondriasis — melancholia. 
"  Dementia,  general  and  partial,  primary  and  secondary. 
"  States  of  mental  weakness — chronic  mania  and  melancholia,  recurrent  in- 
sanity, delusional  insanity,  general  paralysis  of  the  insane. 
"  Paralytic  insanity — epileptic  insanity. 
"  Puerperal  insanity — postconnubial,  puerperal,  lactation. 
"  Toxic  insanity — alcohol,  lead,  opium,  chloral,  etc., — gout. 
"  Visceral  insanity — renal,  cardiac,  and  pulmonary. 

"  Insanity  with  syphilis — myxoedema — Graves's  disease — asthma — diabetes. 
"  Idiocy  in  its  various  degrees." 

Before  giving  his  own  classification  he  gives  that  of  the  College  of 
Physicians  of  London,  which  he  calls  the  ideal  classification. 

The  chapter  on  causes  is  an  interesting  inquiry  into  the  assigned 
causes  of  insanity — predisposing  and  exciting,  general  and  special. 

Following  the  chapter  upon  causation,  Dr.  Savage  takes  up,  in  the 
order  of  his  classification,  the  various  forms  of  insanity  and  discusses 
them  in  an  able  manner. 

The  author  is  not  only  an  able  clinical  teacher  but  an  experienced 
pathologist.  His  experience  in  the  wards  of  Bethlem  and  in  the  patho- 
logical laboratory  have  not  led  him  to  take  a  very  optimistic  view  of 
our  present  knowledge  of  the  pathology  of  insanity.  He  says  in  one  of 
the  earlier  pages : 

"  I  may  say  that,  with  my  experience  of  years,  and  after  seeing  many 
hundreds  of  post-mortem  examinations  of  the  bodies  of  the  insane,  I  have  met 
with  few  coarse  changes  within  the  skull,  and  even  with  the  higher  powers  of 
the  microscope  all  that  can  often  be  detected  may  be  evidences  of  change  in 
the  nutrition  of  the  connective  tissue  of  the  brain." 

As  regards  the  future,  he  is  more  hopeful ;  he  says : 

"  The  time  will  come  when  the  inter-relations  between  the  millions  of  nerve 
cells  with  their  manifold  processes,  and  their  dependence  for  healthy  action 
upon  healthy  blood  and  pure  air,  will  be  better  understood." 

He  likens  the  brain  to  the  kaleidoscope,  in  w'hich  the  pattern  of  the 
image  changes  while  the  parts  remain  the  same,  being  simply  changed 
in  their  relations  to  each  other. 

When  will  the  physiologist  or  pathologist  appear  who  shall  teach  us 
to  recognize  the  characters  and  determine  the  causes  of  these  changes  of 
relation?  And  when  shall  we  be  taught  how  to  restore  the  parts  to  their 
original  pattern  ? 

In  view  of  the  recent  publication  of  Dr.  Earl's  work  on  the  Curability 
of  Insanity,  Dr.  Savage's  remarks  upon  the  subject  are  of  interest : 

"  There  is,  in  fact,  a  very  strong  feeling  prevalent  that  a  patient  once 
having  had  an  attack  of  insanity  is  never  cured  under  any  circumstances. 
This  I  shall  oppose  entirely ;  but  I  acknowledge  that  a  very  considerable  pro- 
portion are  maimed  in  one  way  or  another  by  an  attack  of  insanity." 


BALLET,  BOSS,  APHASIA. 


195 


In  the  matter  of  treatment,  Dr.  Savage  will  be  found  to  agree  in  all 
essential  matters  with  the  practice  of  the  better  asylums  of  the  United 
States.  He  is  in  favor  of  asylum  care  for  the  majority  of  cases,  as 
affording  the  best  hope  of  recovery.  Of  home  care,  he  says  that  it  is 
"  only  suitable  for  cases  in  which  there  is  a  hope  of  speedy  recovery, 
and  where  there  are  judicious  friends  and  sufficient  space."  Except  in 
special  instances  he  deprecates  what  is  called  "  single  care,"  and  is  con- 
vinced that  other  things  being  equal,  more  patients  get  well  when  asso- 
ciated with  others  than  when  under  single  charge. 

The  manual  is  written  in  a  pleasing  style  and  can  be  read  by  those 
even  of  large  experience  with  profit.  It  will  be  found  to  confirm  by  its 
well-digested  clinical  facts  a  doubtful  opinion  in  the  minds  of  some  or  to 
correct  a  mistaken  conclusion  for  others;  For  the  general  practitioner, 
it  perhaps  presupposes  too  much  an  elementary  knowledge  of  the  sub- 
ject, which,  unfortunately,  the  majority  does  not  possess,  but  even  the 
general  practitioner  will  find  the  work  of  great  interest  and  value. 

E.  N.  B. 


La  Langage  Interieur,  et  les  diverses  formes  de  l'Aphasie.  Par 
Gilbert  Ballet,  Professeur  agrege  a  la  Faculte  de  Medecine  de  Paris. 
Pp.  xvi.  174.    Paris :  Germer  Balliere  et  Cie,  1886. 

Inner  Speech  and  the  Different  Forms  of  Aphasia.  By  Gilbert 
Ballet,  Associate  Professor  of  the  Faculty  of  Medicine  in  Paris. 

On  Aphasia  ;  Being  a  Contribution  to  the  Subject  of  the  Dissolu- 
tion of  Speech  from  Cerebral  Disease.  By  James  Boss,  M.D., 
LL.D.    Pp.  ii.  128.    London :  J.  &  A.  Churchill,  1887. 

Each  of  these  attractive  little  volumes  presents,  in  a  clear  and  com- 
prehensive manner,  the  results  of  recent  investigations,  both  clinical  and 
pathological,  upon  the  interesting  condition  of  disturbance  of  speech. 

Ballet  approaches  the  subject  from  the  psychological  side,  and  dis- 
cusses the  mental  processes  involved  in  spoken  language.  He  shows 
that  men  differ  from  one  another  in  the  manner,  as  well  as  in  the  matter, 
of  their  thinking.  Some  listen  to  the  ideas  as  they  flow  through  the 
mind,  hearing  the  murmur  of  the  stream  of  thought  (les  auditifs). 
Others  are  spectators  of  a  series  of  mental  pictures,  and  are  continually 
watching  the  changes  that  pass  before  the  mind's  eye  (les  visuels). 
Others  still,  can  only  grasp  an  idea  by  a  sort  of  inward  effort  of  articula- 
tion, a  silent  process  which,  in  children,  is  often  evident  in  the  motion  of 
the  lips  which  accompanies  early  attempts  at  reading  (les  motifs).  Thus, 
in  our  inward  speech  there  are  various  elements,  one  of  which  predomi- 
nates in  every  one. 

This  may  become  more  evident  if  Charcot's  analysis  of  the  mental 
constituents  of  the  idea  "bell"  be  considered.  This  idea,  like  that  of 
any  other  object,  is  made  up  of  a  number  of  mental  pictures.  There  is 
the  picture  of  the  appearance  of  the  bell — the  visual  memory  ;  there  is 
the  picture  of  the  sound  of  the  bell  as  it  rings — the  auditory  memory ; 
there  is  the  picture  of  the  sound  of  the  word  "  bell "  when  spoken — (he 
word-hearing  memory ;  there  is  the  picture  of  the  word  "  bell  "  as  printed 


196 


REVIEWS. 


or  written — the  word-seeing  memory ;  there  is  the  picture  of  the  mus- 
cular movements  necessary  to  say  and  to  write  the  word  "  bell " — the 
word-uttering,  and  the  word- writing  memories.  These  pictures  together 
form  the  complex  mental  image  involved  in  the  idea  "  bell ;"  and  the 
same  is  true  of  the  idea  of  any  concrete  object.  It  will  be  noticed  that 
four  of  these  mental  pictures  are  sensory  in  their  origin,  and  that  two 
are  motor.  All  are  necessary  to  the  perfect  representation  of  the  idea 
to  the  mind,  or  for  perfect  expression  in  speech.  Aphasia,  according  to 
Ballet,  consists  of  the  loss  of  one  or  more  of  these  mental  pictures,  and 
is  sensory  or  motor  according  to  the  character  of  the  image  lost.  Loss 
of  visual  or  auditory  memories  is  rare,  and  may  not  affect  speech, 
although  it  is  usually  associated  with  aphasia.  Loss  of  the  word- 
hearing  memory  is  known  as  word-deafness,  or  amnesia.  Loss  of  the 
word-seeing  memory  as  word-blindness,  or  alexia.  Loss  of  the  word- 
uttering  memory  constitutes  aphasia  proper.  Loss  of  the  word-writing 
memory  produces  agraphia.  These  forms  may  be  combined  in  any  one 
case,  but  often  occur  alone. 

It  is  evident  that  the  work  of  Ballet  is  founded  upon  the  lectures  of 
Charcot,  recently  collected  and  issued  by  Bernard  ("De  FAphasie  et  de 
ses  diverses  formes,"  Le  Progres  Medical),  and  that  its  claim  to  originality, 
either  of  conception  or  presentation,  is  very  slight.  Nevertheless,  it  is 
clearly  written,  and  as  it  is  issued  as  a  volume  of  the  Bibliotheque  de 
philosophic  contemporaire,  it  may  be  regarded  as  a  successful  semi- 
popular  presentation  of  the  subject. 

Boss  takes  up  the  subject  of  aphasia  from  the  clinical  standpoint,  and 
gives  most  interesting  and  well-studied  cases  illustrating  the  varieties  of 
the  "  dissolution  of  speech."  He  divides  aphasia  into  a  motor  and  a  sen- 
sory form,  but  admits  that  these  are  frequently  combined.  Motor  aphasia 
presents  three  varieties :  (1)  aphemia,  which  presents  many  degrees 
from  a  slight  defect  in  the  power  of  expressive  speech  up  to  absolute 
wordlessness ;  (2)  agraphia,  which  may  vary  from  a  condition  in  which 
the  patient  makes  mistakes  in  spelling  and  diction,  up  to  a  state  in  which 
he  cannot  write  or  copy  a  single  letter ;  and  (3)  amimia,  a  condition  in 
which  gesture  language  is  suspended,  and  which,  so  far  as  known,  is  a 
theoretical  form  not  yet  observed.  Sensory  aphasia  also  presents  three 
varieties  :  (1)  the  aphasia  of  recollection,  in  which  the  idea  of  an  object 
fails  to  revive  its  corresponding  word ;  (2)  psychical  blindness,  in  which 
the  visual  image  of  the  object  is  lost,  or  its  word-image  is  lost  (word- 
blindness),  or  even  the  letters  of  the  alphabet  are  no  longer  recognized 
(literal  blindness)  ;  or  in  which  there  may  be  a  partial  perceptive  blind- 
ness, which  is  not,  however,  to  be  regarded  as  aphasia ;  (3)  psychical 
deafness,  in  which  the  acoustic  imagery  is  impaired,  the  words  being  no 
longer  recognized  when  heard  (word-deafness),  or  at  the  command  of 
the  memory  when  needed ;  and  this  in  its  extreme  form  may  be  partial 
perceptive  deafness  in  which  ordinary  sounds,  such  as  the  tapping  on  a 
door,  are  no  longer  understood.  Ross  distinguishes  four  or  five  different 
degrees  of  each  of  these  forms  of  aphasia,  a  subdivision  which  seems 
somewhat  artificial,  and  complicates  the  subject  unduly. 

Paraphasia,  in  which  the  motor  and  sensory  forms  are  combined,  pre- 
sents several  degrees  from  the  mere  substitution  of  a  wrong  word  for  the 
right  one,  up  to  the  condition  in  which  the  patient  talks  gibberish ;  the 
intermediate  forms  being  the  condition  in  which  the  patient  is  compelled 


BULLETIN   OF   THE   U.  S.  GEOLOGICAL   SURVEY.  197 


to  substitute  for  the  correct  word  a  paraphrase  of  it,  or  a  wholly  inap- 
propriate term,  and  the  condition  in  which  the  patient  fails  to  aj)preciate 
the  right  name  when  uttered  in  his  hearing. 

Paragraphia  is  described  as  the  condition  in  which  the  individual  is 
unable  to  write  correctly,  or  to  write  a  continuous  sentence,  or  to  write  a 
single  word,  or  to  copy. 

Paralexia  may  consist  of  a  transposition  of  words  in  reading  aloud, 
which  may  be  so  extreme  as  to  result  in  a  gibberish  altogether  unintel- 
ligible to  the  listener. 

Each  of  these  forms  is  shown  to  have  as  a  pathological  basis  a  defi- 
nite lesion  in  the  brain  at  one  part  or  other  of  the  cortex.  Motor 
aphasia  is  caused  by  a  lesion  of  the  left  third  frontal  convolution. 
Agraphia  is  produced  by  a  lesion  in  the  second  frontal  convolution. 
Word-deafness  is  due  to  destruction  of  the  first  and  second  temporal 
convolutions  in  their  posterior  part.  Word-blindness  is  produced  by  a 
lesion  of  the  inferior  parietal  lobule  and  angular  gyrus.  Paraphasia, 
paragraphia,  and  paralexia  are  ascribed  to  lesions  involving  two  convo- 
lutions in  distant  parts  at  once,  or  to  a  very  large  lesion  involving  an 
extensive  area  of  the  cortex.  The  usual  explanation  of  these  latter  forms, 
urged  by  German  authorities,  is  that  they  are  due  to  destruction  of  the 
nerve  fibres  which  pass  beneath  the  cortex  and  associate  the  various 
areas  with  one  another  ;  but  Ross  does  not  favor  this  view. 

The  latter  half  of  the  book  contains  a  careful  critical  study  of  the 
various  explanatory  schemes  which  have  recently  been  offered  by  writers 
on  aphasia;  those  of  Kussmaul,  Charcot,  Lichtheim,  and  Broadbent 
being  shown  and  discussed.  To  any  one  who  cares  to  enter  upon  a 
minute  study  of  aphasia,  and  to  learn  the  many  important  bearings  of 
the  subject  upon  the  psychological  problem  of  the  relation  of  mind  and 
brain,  this  part  of  the  work  will  be  of  great  interest  and  value.  Ross 
follows  Hughlings  Jackson  very  closely  in  his  development  of  the  theory 
of  the  evolution  and  dissolution  of  speech.  The  originality  of  the  author 
is  not  however  lost,  and  his  critical  insight  and  wide  clinical  experience 
combine  to  keep  the  discussion  within  medical  lines.  The  easy  diction 
and  attractive  style  make  the  work  an  entertaining  addition  to  the 
literature  of  aphasia.  M.  A.  S. 


Department  of  the  Interior.  Bulletin  of  the  United  States 
Geological  Survey,  No.  32.  Mineral  Springs  of  the  United 
States.    8vo.  pp.  235.    Washington :  Government  Printing  Office,  1886. 

Although  the  number  and  extent  of  the  so-called  mineral  springs  of 
the  United  States  are  never  realized  till  one  reads  this  Bulletin  of  the 
United  States  Geological  Survey,  a  careful  perusal  of  the  results  there 
obtained  go  to  show  that  the  number  of  springs  possessing  any  real 
value  as  medicinal  agents  is  comparatively  small. 

Many  of  the  so-called  hot  springs  have  been  found  to  possess  no  larger 
amounts  of  mineral  matter  than  ordinary  indifferent  waters,  and  largely 
depend  on  their  heat  for  any  therapeutic  powers  which  they  may  possess. 

The  chief  value  to  the  ordinary  medical  practitioner  of  a  publication 
of  this  kind  is  to  enable  him  to  discover  whether  or  not  springs  possess- 


198 


REVIEWS. 


ing  powers  for  good  exist  in  accessible  regions  in  this  country,  and 
"whether,  if  accessible,  they  approach  the  foreign  waters  closely  enough 
to  be  substituted  for  them. 

The  space  allotted  to  a  review  of  this  character  does  not  permit  of  an 
extended  comparison  of  the  mineral  waters  of  this  country  and  abroad, 
and  for  this  reason  only  the  most  important  will  be  considered. 

Roughly  stated,  the  springs  which  are  generally  looked  upon  as 
valuable  for  medicinal  purposes  contain  one  or  more  of  the  following 
ingredients ;  namely,  sulphur,  chalybeate  matters,  arsenic,  salines,  and 
sulphuric  acid,  and  perhaps  lithium.  Suffice  it  to  state  that  in  the 
United  States  we  have  waters  possessing  all  these  properties  to  a  marked 
degree.  Not  only  have  we  springs  in  this  country  which  to  a  large 
extent  may  be  used  in  place  of  European  waters,  but  in  some  instances 
the  springs  of  the  United  States  actually  surpass  in  a  considerable  degree 
those  of  other  countries.  Thus,  the  so-called  saline  springs,  such  as 
Saratoga,  compare  very  favorably  with  corresponding  waters  on  the 
other  side,  while  the  Balston  springs  of  New  York  not  only  surpass  all 
foreign  springs  in  mineral  constituents  (135  grains  per  pint),  but  also 
excel  the  saline  waters  of  Homburg,  Kissingen,  Wiesbaden,  and  Selters 
in  their  percentage  of  carbonic  acid  (53  cubic  inches).  Not  only  does 
this  remarkable  spring  contain  these  constituents  in  such  large  amount, 
but  it  also  possesses  a  large  proportion  of  the  carbonate  of  lithia — 0.701 
of  a  grain. 

The  springs  of  the  United  States  corresponding  most  closely  to  the 
celebratedfones  abroad  are,  probably,  the  following  : 

Sulphur  springs :  Lower  Blue  Lick,  Nicholas  Co.,  Ky. ;  Sharon, 
Schoharie  Co.,  N.  Y. ;  White  Sulphur,  Greenbrier  Co.,  Va. ;  Salt  Sulphur, 
Monroe  Co.,  W.  Va.  Epsom  salt :  Bedford,  Bedford  Co.,  Pa.  Sodium 
chloride:  Hathorne,  Saratoga,  N.  Y. ;  Balston,  Saratoga  Co.,  N.  Y. 
Iron :  Oak  Orchard,  Genesee  Co.,  N.  Y. ;  Rockbridge  Alum,  Rockbridge 
Co.,  Va. ;  Cooper's  Wells,  Hinds  Co.,  Miss.  Glauber  salts  :  Crab  Orchard, 
Lincoln  Co.,  Ky. ;  Midland,  Midland  Co.,  Mich. 

As  regards  the  geographical  distribution  of  mineral  springs  in  the 
United  States,  it  is  found  that  of  the  Eastern  States,  New  York  and 
Virginia  have  the  largest  number  of  active  medicinal  waters,  while  the 
States  and  Territories  west  of  the  Mississippi  River  contain  nearly  all  the 
important  thermal  springs  we  possess,  with  the  exception  of  a  few 
scattered  along  the  Appalachian  chain  in  Virginia  and  one  at  Lebanon, 
N.  Y. 

It  is  probable,  too,  that  large  numbers  of  the  so-called  medicinal 
springs  do  not  possess  constituents  capable  of  acting  in  any  way  di- 
rectly on  the  organism  but  rather  do  good  by  "  sluicing "  the  renal 
organs  and  thereby  aiding  elimination,  or,  when  used  in  baths,  by  in- 
creasing the  action  of  the  skin. 

In  conclusion,  the  labor  involved  in  such  a  report  can  scarcely  be  esti- 
mated, and  those  having  it  in  charge  are  to  be  congratulated  on  presenting 
the  public  with  so  interesting  and  valuable  a  compilation.  The  benefits  of 
such  publications  have  already  been  partially  pointed  out,  and  are  too 
obvious  to  need  further  comment.  The  only  fault  that  can  be  found 
with  it  is  in  the  index,  which,  while  good  and  copious,  gives  only  the 
name  of  each  spring  without  stating  its  chief  constituent,  and,  as  a  con- 
sequence, one  is  forced  to  look  up  many  references  before  he  is  able  to 
find  any  number  of  a  given  variety  of  waters  for  comparison.  Lender 


AMERICAN   OPHTH  ALMOLOGICAL  SOCIETY. 


199 


the  act  of  Congress,  this  Bulletin  can  be  obtained  by  enclosing  a  money 
order  for  20  cents  to  the  Director  of  the  United  States  Geological 
Survey,  Washington,  D.  C.  H.  A.  H. 


Transactions  of  the  American  Ophthalmologics  Society.  Twenty- 
second  Annual  Meeting,  1886.  8vo.  pp.  220.  Boston,  published  by  the 
Society. 

This  second  part  of  the  fourth  volume  is  the  largest  annual  contribu- 
tion which  the  Society  has  yet  made  to  its  transactions,  and  the  matter 
it  contains  makes  it  by  far  the  most  important  American  contribution 
of  the  year  to  the  literature  of  ophthalmology  ;  many  of  the  papers,  too, 
are  of  general  interest. 

The  retinal  lesions  connected  with  albuminuria  are  extensively  dis- 
cussed :  Dr.  C.  S.  Bull  contributing  an  "  Analysis  of  One  Hundred  and 
Three  Cases  of  Exudative  Neuro-retinitis  Associated  with  Bright's  Dis- 
ease ;"  Dr.  George  C.  Harlan,  a  case  of  "  Thrombosis  and  Perivasculitis 
of  the  Retinal  Vessels ;"  and  Dr.  S.  D.  Risley  a  case  of  "  Albuminuria 
of  Pregnancy  ;  Retinitis  ;  Induced  Premature  Delivery." 

Bull  excluded  all  cases  due  to  scarlatina  or  pregnancy,  and  reported 
only  such  as  he  had  been  able  to  follow  to  their  termination,  or  to  the 
date  of  the  report.  His  patients  included  fifty-six  men  and  forty-seven 
women.  Both  eyes  were  affected  in  ninety -three  cases;  hemorrhages 
occurred  in  one  or  both  eyes  of  sixty-nine  patients ;  while  all  but  three 
came  to  present  evidence  of  cardiac  hypertrophy  with  or  without  valvu- 
lar disease.  In  thirty-two  cases  vision  improved  under  treatment,  but 
without  absorption  of  the  glistening  exudation  at  the  macula. 

In  this  series  of  cases  the  gravity  of  the  prognosis  is  well  illustrated. 
Thirty  had  died  within  six  months  after  they  were  first  seen,  and  in  the 
next  six  months  twenty-seven  more.  In  the  second  year  eighteen  died ; 
in  the  third  year,  six  ;  in  the  fourth  year,  four ;  and  in  the  sixth  year, 
one.  Of  the  seventeen  still  living,  fourteen  had  been  first  seen  within 
the  last  six  months ;  two  others  within  a  year ;  and  only  one  had  been 
first  seen  seven  years  ago.  In  the  discussion  Dr.  Gruening  stated  that 
of  one  hundred  cases  he  had  collated,  none  had  lived  more  than  two 
years. 

For  those  cases  arising  from  scarlatina,  and  especially  in  those  from 
pregnancy,  the  prognosis  is  entirely  different.  This  is  well  illustrated  in 
Dr.  Risley's  case,  where  the  patient,  after  being  almost  blind,  with  the 
urine  loaded  with  albumen,  and  after  premature  delivery  becoming  un- 
conscious and  hemiplegic,  and  subsequ  '  exhibiting  aphasia,  made 
an  excellent  recovery,  vision  coming  inoe  p0sit5  right  eye  from  counting 

fingers  at  two  feet  to  and  in  the  lt*cu*ar;om—  to  —   ;  while  the 

6  xxx  -cause        cc  xx 

very  extensive  retinal  exudation  disapesat/cl  entirely  from  the  latter, 
and  left  but  a  few  splotches  on  the  eye-      «nd  of  the  former. 

Dr.  Harlan  describes  a  case  of  almostit  aiversal  change  in  the  retinal 
vessels  of  one  eye,  with  small  hemorrhages  and  other  slight  retinal 
changes  in  the  other  eye,  in  a  patient  who  shortly  afterward  had  albu- 


200 


EEVIEWS. 


minuria  and  partial  left  hemiplegia.  The  case  is  illustrated  by  a  plate 
showing  the  appearance  of  the  fundus ;  the  darker  red  of  the  normal 
vessels  being  replaced  by  broader  bands  of  glistening  white. 

It  has  from  time  to  time  been  remarked  that  "  Listerism  "  and  the 
"  gospel  of  cleanliness"  seem  to  arouse  no  general  interest  among  ophthal- 
mic surgeons.  The  reason  doubtless  is,  that  it  has  never  been  customary 
to  invite  assistants  to  thrust  their  dirty  hands  into  the  corneal  incision ; 
while  the  dictum  of  high  authority  forbade  the  introduction  of  any  in- 
strument not  absolutely  necessary,  and  the  necessity  for  perfectly  keen 
edges,  and  smooth-working  joints  invites  to  scrupulous  cleanliness  of 
such  instruments  as  must  be  introduced.  Then,  too,  the  constant  bath- 
ing of  the  eye  by  the  lachrymal  secretion,  and  the  outpouring  of  the 
aqueous  humor  through  any  corneal  incision  tended  to  prevent  infection. 
So  that  the  ophthalmic  surgeon  practised  asepsis,  as  the  rustic  talked 
prose,  without  knowing  it.  But  although  this  was  generally  true,  it 
occasionally  happened  that  in  the  most  promising  case,  after  the 
neatest  operation,  an  eye  would  be  lost  by  general  purulent  inflamma- 
tion ;  indicating,  that  to  be  right  by  chance,  is  not  so  safe  as  to  be  right 
by  definite  knowledge.  Attention  is  called  to  the  subject  by  Dr.  H. 
Knapp,  by  some  "  Remarks  on  Pyogenic  Microorganisms,  with  Demon- 
strations and  Experiments."  The  demonstrations  included  the  making 
of  cataract  extractions  upon  the  eyes  of  four  rabbits ;  on  the  left  eyes 
with  clean  instruments,  on  the  right  with  instruments  contaminated  with 
staphylococci.  The  operations  were  rudely  done,  and  the  injury  to  the 
left  eyes  increased  by  stirring  the  deeper  parts  with  a  sterilized  hook. 
Yet  while  the  right  eyes  all  showed  free  suppuration  when  exhibited 
twenty-four  hours  later,  three  of  the  left  eyes  remained  free  from  suppu- 
ration throughout,  and  the  fourth,  showing  it  at  a  later  date,  was  be- 
lieved to  have  been  contaminated  by  the  right  eye  of  another  rabbit 
kept  in  the  same  box,  so  that  their  heads  were  in  close  contact.  Dr. 
Knapp  believes  that  for  eye  surgery  smooth-cutting  instruments  are  best 
sterilized  by  washing  in  clean  water,  and  wiping  and  polishing  on  a 
clean  towel ;  because  any  efficient  antiseptic  solution  is  likely  to  dull  a 
cutting  edge.  Tarnished  instruments  cannot  be  cleaned  in  this  way,  and 
rough  instruments  must  be  placed  in  some  antiseptic  solution. 

Cataract  extraction  has  its  usual  share  of  papers  and  discussion.  Dr. 
G.  Strawbridge  offers  a  "  Report  of  Two  Hundred  and  Sixty-one  Cases ;  " 
Dr.  H.  Knapp,  a  paper  on  "  Cataract  Extraction  without  Iridectomy ; " 
Dr.  D.  Webster,  "  Report  of  Fifty  Cases  of  Cataract  Extraction  with 
Remarks  ; "  Dr.  H.  D.  Noyes,  "  Extraction  of  Hard  Cataract — Death 
on  the  Fifth  Day — Examination  of  the  Eye."  The  principal  interest 
in  these  papers  and  the  extended  "  discussion "  which  follows  them, 
attaches  to  the  operation  of  extraction  without  iridectomy,  as  to  which 
there  is  an  agreement  that  its  value  and  the  classes  of  cases  to  which 
it  is  suited  are  not  yetr  invoi  determined  ;  to  the  washing  out  of  the 
conjunctival  sac  and  trfinchanor  chamber  with  antiseptic  solutions, 
which  is  recommended ;  sPg  and  the  use  of  cocaine  for  operations  threat- 
ening the  integrity  of  the'eady  ia. 

Bearing  on  the  latter  poflamenveral  speakers  report  bad  effects  from 
the  free  use  of  strong  solution,  ^  But  there  seems  to  be  a  general  agree- 
ment that  smaller  quantities,3ta/ a  drop  or  two  of  a  two  or  four  per  cent, 
solution,  answer  the  purposes' of  a  local  anaesthetic  about  as  well  and  are 
free  from  danger.    It  is  to  be  feared  that  the  danger  which  cocaine 

ft 


AMEEICAN  OPHTHALMOLOGICAL  SOCIETY. 


201 


brings  to  the  non- vascular  cornea,  both  by  the  anaesthesia  which  allows 
the  unrecognized  presence  of  irritants,  and  the  lessening  of  its  nutritive 
supply  by  contraction  of  the  neighboring  vessels,  is  not  yet  sufficiently 
understood  by  many  who  prescribe  it.  Recently  the  writer  has  seen 
tedious  and  very  painful  inflammation  of  the  cornea  with  extensive 
superficial  sloughing  and  consequent  opacity,  caused  by  frequently  re- 
peated applications  of  a  four  per  cent,  solution  of  cocaine  to  relieve  the 
pain  of  an  acute  catarrhal  conjunctivitis.  The  attending  physician  had 
ordered  the  solution  to  be  used  at  considerable  intervals,  the  patient 
found  it  gave  relief,  which  was  of  short  duration,  and  repeated  the 
application  with  each  recurrence  of  the  pain.  There  resulted  the  loss 
of  most  of  the  surface  of  the  cornea,  leaving  an  exquisitely  painful 
ulcer  and  permanent  damage  to  the  sight. 

Returning  to  our  subject,  we  find  a  paper  by  Dr.  B.  E.  Fryer  on 
"  The  Use  of  Hot  Water  in  Some  of  the  Conj  unctival  and  Corneal  In- 
flammations."   Not  warm,  but  hot  water  is  to  be  used.    He  says  : 

"I  was  astonished  in  the  earlier  cases  (it  being  new  experience  to  me)  at 
the  tolerance  and  even  indifference  to  the  heat  by  the  patient.  Water  in 
which  I  could  not  retain  my  hand  a  minute,  apparently  made  no  unpleasant 
impression  on  individuals  who  had  used  it  at  the  same  temperature  for  a  few 
hours  or  for  a  day  or  two.  The  temperature  of  the  water  should  not  be  lower 
than  140°,  and  as  much  higher  as  can  be  tolerated ;  of  course,  short  of  blis- 
tering." 

Its  use  was  recommended  in  purulent  and  catarrhal  conjunctivitis, 
phlyctenular  ophthalmia,  and  in  corneal  inflammations  and  ulcers.  It 
is  especially  effective  in  relieving  the  pain  of  the  latter.  Dr.  Fryer's 
estimate  of  such  treatment  is  confirmed  by  other  members. 

Dr.  Wm.  F.  Norris  offers  "  Some  Remarks  on  Asthenopia  and  the 
Changes  in  Refraction  in  Adolescent  and  Adult  Eyes,"  including  the 
report  of  a  series  of  cases  of  hypermetropia  diminishing  or  passing  over 
into  myopia.  He  regards  diminishing  hypermetropia  and  increasing 
myopia  as  different  stages  of  the  same  process  ;  and  "  would  urge,  there- 
fore, the  careful  correction  of  every  case  of  ametropia  where  there  is 
accompanying  asthenopia."  "All  such  cases  should  be  carefully  meas- 
ured under  a  strong  mydriatic,  as  it  is  impossible  to  correct  them  accurately 
without  it."  While  under  the  influence  of  the  mydriatic  the  eye  should 
be  protected  by  dark  glasses,  lest  the  excess  of  light  "  cause  a  low  grade 
of  chorio-retinitis,  which  it  is  much  easier  to  call  into  existence  than  to 
cure." 

Dr.  J.  A.  Andrews  contributes  a  paper  on  "  The  Electric  Light  as  an 
Illuminator — The  Effect  of  Strong  Light  on  the  Eye;"  based  in  part  on 
the  examination  and  observation  of  eleven  hundred  persons  habitually 
working  by  the  light  of  the  incandescent  lamp  of  Edison.  From  his 
conclusions,  we  quote  : 

"  The  arc  light  in  its  present  state  should  be  positively  rejected  as  unsuitable 
and  actually  harmful  to  the  human  eye,  particularly  on  account  of  its  steadi- 
ness. The  incandescent  light  of  Edison,  because  of  its  steadiness,  adequate 
power,  and  composition,  is  safe,  and  occupies  at  present  the  first  position  as  a 
means  of  artificial  illumination." 

Dr.  W.  F.  Mittendorf  gives  an  account  of  "Two  Epidemics  of  Mol- 
luscum  Contagiosum,"  a  skin  disease,  interesting  the  ophthalmologist 
by  its  predilection  for  the  eyelids.    These  epidemics,  including  nearly 


202 


REVIEWS. 


one  hundred  cases,  throw  some  light  on  the  mooted  question  of  the  con- 
tagiousness of  this  affection. 

Reports  of  cases ;  and  descriptions  of  new  instruments,  tests,  and  pro- 
cedures; with  a  couple  of  papers  on  geometrical  optics,  occupy  the 
remainder  of  the  volume.  E.  J. 


L' Amputation  du  Membre  Superieur  dans  la  Contiguite  du  Tronc. 
(Amputation  Interscapulo-thoracique.)  Par  Paul  Berger,  Chi- 
rurgien  de  l'Hopital  Tenon,  Professeur  Agrege  a  la  Faculte  de  Medecine, 
Membre  de  la  Societe  de  Chirurgie.    G.  Masson  :  Paris,  1887. 

Interscapulo-thoracic  Amputation  of  the  Upper  Extremity.  By 
Prof.  Paul  Berger.    Paris,  1877. 

This  monograph  by  Prof.  Berger  is  a  treatise  upon  amputation  of  the 
upper  extremity  and  scapula,  either  at  one  operation,  or  in  consecutive 
periods.  He  designates  this  procedure  as  "  Interscapulo-thoracic  ampu- 
tation," but  it  is  usually  spoken  of  as  amputation  above  the  shoulder- 
joint.  The  book,  which  is  written  in  the  French  language,  contains  371 
pages,  and  is  illustrated  with  several  woodcuts  and  two  colored  litho- 
graphic plates.  The  style  is  simple,  and  can  be  readily  understood  even 
by  one  whose  knowledge  of  French  is  not  great. 

The  author  states  that  the  meagre  notice  of  this  operation  which  is 
found  in  the  classical  treatises  upon  operative  surgery,  renders  it  desirable 
that  a  thorough  study  of  this  subject  should  be  undertaken,  since  the 
operation,  though  not  often  required,  does  in  some,  otherwise  desperate, 
cases  afford  an  effective  resource.  The  histories  of  fifty-one  cases  culled 
from  literature  or  from  the  personal  experience  of  the  author  are 
recorded,  and  form  the  basis  of  the  excellent  critical  remarks  which 
follow.  The  operation  is  altogether  modern,  the  earliest  case  recorded 
being  that  performed  by  Ralph  Gumming,  a  surgeon  in  the  English 
Navy,  in  1808,  though  Cheselden  figured  a  cured  case  of  accidental 
ablation  of  the  upper  extremity  and  scapula  in  his  Anatomy  of  the 
Human  Body,  published  in  1768. 

After  giving  the  details  of  the  different  operations  which  have  been 
performed,  the  author  considers  the  subject  from  various  standpoints, 
such  as  the  mortality  inherent  to  the  operation,  the  causes  of  death,  the 
accidents  occurring  during  and  after  the  operation,  the  indications  for 
the  operation,  and  the  remote  consequences  which  may  follow  it,  and 
finally  general  considerations  upon  operative  technique.  The  mortality 
varies  with  the  nature  of  the  affection  for  which  the  operation  is  per- 
formed, thus,  in  those  cases  where  amputation  is  performed  for  patho- 
logical causes  the  mortality  is  about  20  per  cent.,  whilst  in  traumatic 
cases  301  per  cent.  die.  The  mortality  of  primary  operations,  in  which 
the  arm  and  scapula  are  removed  at  the  same  time,  is  about  the  same  as 
in  secondary  operations  where  the  shoulder  blade  is  removed  some  time 
subsequent  to  the  primary  operation.  This  is  rather  an  exceptional 
fact,  as  it  is  a  common  observation  that  a  primary  amputation  at  a 
certain  height  is  usually  more  fatal  than  a  secondary  operation  per- 
formed at  the  same  level.    Amongst  the  immediate  results  which  may 


HARRIS,  BEFORE  TRIAL. 


203 


occur  are  hemorrhage,  the  entrance  of  air  into  the  veins,  shock,  and 
purulent  infection.  Air  has  found  entrance  into  the  axillary  vein  upon 
four  occasions,  as  was  announced  by  a  peculiar  gurgling  sound  and 
followed  almost  immediately  by  alarming  sycope.  All  these  patients 
recovered  from  this  accident  with  one  exception. 

This  operation  has  been  performed  for  tumors  of  the  humerus  and 
scapula,  usually  malignant  in  character,  for  osteitis,  and  gunshot  wounds. 
Of  the  fifty-one  cases  reported  eleven  were  done  by  American  surgeons ; 
the  first  complete  ablation  of  the  upper  extremity,  scapula,  and  greater 
part  of  clavicle  at  one  operation,  was  performed  by  Dr.  Dixi  Crosby  of 
the  United  States,  in  1836.  In  conclusion,  this  thesis  contains  about  all 
that  is  known  upon  this  subject,  and  a  careful  perusal  of  its  pages  will 
be  both  interesting  and  instructive.  R.  W. 


Before  Trial.  What  should  be  doxe  by  Cliext,  Solicitor,  axd 
Couxsel.  By  Richard  Harris,  Barrister  at  Law.  Together  with  a 
Treatise  ox  the  Defexce  of  Ixsaxity.  London :  Waterlow  Bros.  & 
Layton,  1886. 

This  small  volume  of  less  than  three  hundred  pages,  is  neither  more 
nor  less  than  it  professes  to  be.  This  in  itself  is  a  virtue.  It  is  written 
in  a  pleasantly  clear  and  concise  style.  It  is  intended  for  lawyers,  and, 
as  a  whole,  therefore,  need  not  be  fully  considered  here ;  but,  as  the 
latter  part  is  quite  as  much  for  the  doctor  as  for  the  lawyer,  we  refer 
to  it.  In  Chapter  XVII.  we  have  the  introduction  to  the  defence  of  In- 
sanity, and  in  the  following  60  pages  the  test  questions,  the  value  of  the 
decision  in  the  McNaghton  case,  and  the  evidence  of  insanity  and 
medical  authority  are  discussed. 

The  note  of  the  introduction  is  very  unlike  that  sounded  by  most 
barristers,  and  our  profession  must  welcome  a  man  who  is  not  tied  and 
trammelled  by  authority.  He  maintains  that  it  is  justice  that  is 
wanted,  the  true  relationship  of  the  established  facts  and  not  the  opin- 
ions of  the  long  dead  and  forgotten.  He  says,  "  I  have  always  felt  that 
the  medical  profession  is  too  little  regarded  in  this  question  of  insanity. 
Medical  men  are  the  very  best,  nay,  they  are  almost  the  only  persons 
capable  of  pronouncing  a  trustworthy  opinion  on  the  subject.  They 
are  too  often  ignored,  as  if  they  always  came  to  get  a  prisoner  acquitted, 
and  as  if  they  had  a  motive  in  so  doing."  We  agree  with  this,  but 
like  our  authority,  we  must  object  to  authority,  for  it  is  only  resting 
on  authority,  to  suppose  that  any  medical  man  can  on  general  principles 
decide  on  insanity :  only  those  can  speak  with  any  degree  of  force  who 
have  lived  with  or  had  many  opportunities  of  studying  nervous  disorders 
in  the  insane. 

In  Part  I.  our  author  instructs  the  solicitor  in  his  preparation  of  the 
brief  when  the  plea  of  insanity  is  raised,  and,  in  passing,  one  may  say, 
all  the  evidence  really  is  taken  as  if  a  crime  is  the  only  point  ever  to  be 
considered  in  relationship  to  insanity.  If  our  author  would  treat  the 
question  of  validity  of  wills  and  devising  capacity  as  well  as  he  has  the 
evidence  in  criminal  trials,  he  would  be  a  public  benefactor. 


204: 


REVIEWS. 


In  giving  directions  for  taking  evidence  on  insanity,  Mr.  Harris  shows 
practical  knowledge  and  clear  insight.  He  reflects  the  popular  opinion 
that  the  plea  of  insanity  must  be  a  last  resource.  As  evidence  of  the 
uncertainty  of  the  relationship  of  symptoms,  he  points  out  that  condi- 
tions or  states  of  unconsciousness,  whether  due  to  somnambulism,  to  epi- 
lepsy, or  drink,  may  render  a  man  ignorant  of  his  act,  and  yet,  while 
for  the  one  a  man  may  be  considered  responsible,  for  the  other  he  is  not. 

Drunkenness  is  no  excuse,  but  insanity  produced  by  drink  is ;  this 
certainly  is  an  anomaly,  for  the  single  lapse  may  land  a  man  on  the 
gallows,  while  habitual  intemperance  may  send  him  to  an  asylum. 

Our  author  gives  examples  showing  that  one  cannot  decide  as  to  re- 
sponsibility by  proving  whether  a  man's  mind  went  with  the  act  or  not, 
and  proceeds  to  emphasize  his  belief  that  the  defence  must  depend  on 
common  sense  and  not  on  technicalities ;  no  definition  of  madness  can 
possibly  be  made,  and,  therefore,  it  is  best  not  to  attempt  to  do  more 
than  lay  facts,  not  definitions,  before  the  jury. 

No  reliance  is  to  be  placed  on  whether  a  man  knew  or  did  not  know 
that  the  act  he  was  perpetrating  was  wrong,  and  the  misconception  of 
the  whole  question  by  judges  is  attributable,  first,  to  universal  inca- 
pacity to  define  insanity,  and,  secondly,  to  total  misconception  by  the 
judges  of  what  insanity  is.  The  tendency  of  judges  to  "  follow  my 
leader,"  and  to  continue  in  doing  unreasonable  things  because  their 
predecessors  did  them,  is  forcibly  exposed. 

Very  properly  he  points  out  the  utter  folly  of  supposing  that  any  one 
test  can  be  applied  to  all  cases,  and  he  shows  that  the  fact  that  a  police- 
man near  at  hand  having  a  restraining  influence  is  not  conclusive  evi- 
dence of  criminal  rather  than  insane  intention. 

"  Madness  has  never  been  incompatible  with  knowledge  except  in 
legal  minds,"  sums  up  the  judgment  of  most  lawyers  on  mental  disorder. 
The  test  of  "  self  restraint "  being  proved  to  be  a  false  one,  the  test  of 
knowledge  of  "right  and  wrong"  is  discussed  and  discarded  as  being 
only  "  the  policeman  at  the  elbow  again." 

"  It  is  enough  to  say  in  answer  to  all  such  unscientific  tests  that  insane 
people,  like  others,  are  subject  to  fear  ;  that  they  refrain  from  commit- 
ting certain  deeds  because  they  know  they  are  wrong  and  that  they  will 
be  punished  if  they  commit  them ;  and  they  sometimes  refrain  because 
they  are  under  the  delusion  that  a  policeman  or  keeper  is  watching 
them." 

Mr.  Harris  sees  clearly  that  the  only  thing  to  be  really  decided  is, 
whether  the  prisoner  is  sane  or  insane,  and  if  he  be  decided  to  be  insane 
nothing  more  should  be  needed.  Doctors  alone  should  decide  or  pro- 
duce facts  proving  this,  and  they  should  be  able  to  consider  the  facts  of 
the  man's  life  and  inheritance,  and  not  merely  the  conditions  associated 
with  the  criminal  act,  though  the  crime  itself  is  often  the  most  marked 
evidence  of  insanity. 

With  all  the  support  given  to  the  medical  witness,  his  weaknesses  are 
also  pointed  out.  "  The  moment  medical  men  take  sides  they  are  use- 
less "  is  a  perfectly  true  statement  of  what,  we  regret  to  say,  is  a  common 
occurrence. 

In  Part  II.  we  have  a  very  full  discussion  of  the  points  in  the  Mc- 
Naghton  case,  and  as  these  are  more  for  lawyers  than  for  doctors  we 
pass  them  over,  only  saying  the  whole  is  very  trenchantly  and  logically 
considered,  and  all  in  favor  of  experience  and  common  sense. 


MACKENZIE,   HYGIENE   OF   THE    VOCAL  ORGANS. 


205 


Part  III.  is  eminently  practical,  showing  the  kind  of  evidence  which 
should  be  produced  and  giving  its  relative  value.  He  advises  that  in 
the  brief,  facts  of  eccentricity  or  injury  should  take  the  place  of  theory. 
Sunstroke  in  India  is  treated  as  sceptically  by  juries  and  judges  as  it  is 
by  asylum  physicians  and  had  better  not  be  trusted  to. 

It  is  only  for  us  to  say  that  our  author  has  a  very  thorough  grasp  of 
the  relative  value  of  medical  indications,  laying  much  stress  on  such 
conditions  as  epilepsy  and  neurotic  inheritance.  He  does  not  quite 
make  clear,  however,  that  there  may  be  brain  disease  without  mental 
disorder,  and  we  feel  it  would  be  unwise  to  loosen  his  faith  in  the  fixed 
and  determined  connection  between  mind  and  matter  lest  he  should 
become  half-hearted  in  the  future  in  the  defence  of  our  professional 
knowledge.  And  now  we  must  leave  this  book  with  a  very  sincere  hope 
that  it  will  be  widely  read  by  both  lawyers  and  doctors. 

We  are  inclined  to  think  in  one  way  that  it  is  too  long  and  in  another 
it  is  defective,  and  our  desire  would  be  that  the  more  useful  and  prac- 
tical parts  should  be  retained  in  any  future  edition,  but  that  the  discus- 
sion on  the  McNaghton  case  and  the  judges'  opinions  should  be  enlarged 
upon  and  printed  apart,  and  that  other  points,  such  as  disposing  and 
contracting  capacity,  should  be  treated. 

The  author  would  thus  give  us  a  good  handbook  of  great  medico- 
legal value. 


The  Hygiene  of  the  Vocal  Organs.  A  Practical  Handbook  for 
Singers  and  Speakers.  By  Morell  Mackenzie,  M.D.  Lond.  Third 
edition.  12mo.  pp.  230,  illustrated.  London :  Macmillan  &  Co.,  and  New 
York,  1887. 

As,  according  to  the  preface,  every  singer  or  actor  of  note  in  Great 
Britain,  with  hardly  an  exception,  has  at  one  time  or  another  come 
under  the  author's  hands,  it  was  to  be  expected  that  his  Handbook 
would  have  a  large  circulation ;  and  so  a  third  edition  has  been  issued 
within  a  few  months  of  the  issue  of  the  first. 

Being  intended  for  the  general  public,  little  note  is  requisite  in  this 
journal.  While  information  and  advice  are  given  to  singers  and  speakers 
with  considerable  detail,  exception  is  taken  as  to  the  necessity  for  their 
knowing  anything  about  the  anatomy  and  physiology  of  their  vocal 
and  articulating  organs.  Amid  occasional  exhibitions  of  good,  dry 
humor,  we  notice  with  surprise  some  undignified  pseudocaustic  raillery 
— i.  e.,  against  teachers  and  others  who  have  endeavored  to  go  over  the 
same  and  similar  ground,  and  with  whose  views  and  results  there  is  some 
discordance  in  the  context.  Pictures  12  and  13,  of  the  appearances  of 
the  glottis  in  the  head  and  falsetto  registers,  with  an  elliptic  opening  in 
the  middle  third  of  the  glottis,  must  surely  be  exceptional. 

Like  all  the  advice  given  by  Dr.  Mackenzie  to  his  colleagues,  the 
advice  given  to  his  patients  and  their  class  is  in  this  book  good  and 
commendable  ;  and  to  English-speaking  physicians  treating  singers  and 
speakers,  it  will  be  of  almost  equal  value.  J.  S.  C. 


206 


REVIEWS. 


Diseases  of  the  Ear,  and  their  Treatment.  By  Arthur  Hartmann, 
M.D.  (Berlin) ;  translated  from  the  third  German  edition  by  James  Ers- 
kine,  M.B.  8vo.  pp.  xiv.  283.  Edinburgh:  Young  J.  Pentland.  New 
York :  G.  P.  Putnam's  Sons,  1887. 

In  the  translator's  preface  we  find  that  "  this  translation  has  been 
undertaken  with  the  view  of  placing  in  the  hands  of  English  prac- 
titioners and  students  a  book  specially  suited  to  their  requirements." 
If  it  had  been  said  that  the  task  was  undertaken  in  order  to  place  before 
English  readers  one  of  the  best  German  works  on  otology,  we  should  not 
have  demurred.  We  must,  however,  enter  our  protest  against  the  sug- 
gestion contained  in  the  above  sentence,  that  there  are  not  many  excel- 
lent works  written  by  English  and  American  authors  in  their  mother 
tongue.  The  names  of  many  such  will  at  once  present  themselves  to  the 
reader  if  he  is  interested  in  aural  surgery. 

Dr.  Hartmann's  work  is,  however,  excellent,  and  as  a  book  of  reference 
most  valuable.  At  the  same  time,  we  venture  to  doubt  whether  it  is 
sufficiently  elementary  for  the  student  or  young  practitioner  who  has  not 
had  the  advantage  of  clinical  instruction  in  otology. 

We  are  glad  to  see  that  in  discussing  "  otitis  externa  diffusa/'  the  view 
is  expressed  that  this  affection  is  commonly  either  secondary  to  inflam- 
mation of  the  middle  ear,  or  due  to  irritants — chemical,  thermal,  or 
mechanical. 

With  reference  to  exostoses  of  the  meatus  it  seems  to  us  that  the  author 
contradicts  himself  in  the  following  sentences,  which  have  been  verified 
by  consulting  the  German  work :  "  This  [i.  e.,  treatment]  is  limited  to 
removal  of  obstructing  matter  so  long  as  the  contraction  is  not  very 
great,  and  the  dulness  of  hearing  is  only  caused  by  temporary  obstruc- 
tion of  the  space  which  exists."  .  .  .  "As  a  rule,  the  exostosis 
should  be  removed  as  early  as  possible,  especially  if  still  growing,  as 
the  operation  is  more  easily  performed  the  less  the  meatus  is  occluded." 

The  advice  given  on  page  145  is  perhaps  not  quite  in  accordance  with 
the  views  of  English  and  American  aurists,  many  of  whom  regard  the 
use  of  bougies  for  the  Eustachian  tube  with  suspicion  if  not  distrust. 

In  the  section  on  "  Chronic  Inflammation  of  the  Middle  Ear  without 
Exudation,"  we  find  the  various  methods  of  treatment  discussed ;  we 
would,  however,  take  exception  to  the  statement  that  "  vapor  of  chloride 
of  ammonium,  which  has  been  in  use  for  a  long  time,  is  now  rarely  em- 
ployed." We  think  that  one  of  the  forms  of  chloride  of  ammonium 
inhalers  now  in  common  use,  is  likely  in  such  cases — provided  always  the 
case  is  or  has  been  of  catarrhal  origin — to  be  of  great  service  after 
thorough  patency  of  the  Eustachian  tubes  has  been  secured.  At  the 
conclusion  of  the  same  chapter  the  author  says  :  "  If  no  benefit  can  be 
obtained  by  the  above  modes  of  treatment,  operations  must  be  resorted 
to."  This  is  dangerous  advice,  doubly  dangerous  when  it  appears  in  a 
work  written  for  students.  The  operations,  afterward  referred  to,  are 
some  of  them  perilous,  and  most  of  them  commonly  useless — e.  g.,  para- 
centesis by  the  galvanic  cautery,  tenotomy  of  the  tensor  tympani,  and 
excision  of  the  membrana  tympani  and  ossicles.  We  believe  that  this 
last-named  proceeding  may  have  a  future  before  it,  but  we  maintain 
that  the  time  has  not  come  when  it  can  safely  be  recommended  in  an 


EWALD,  GENERAL   AND  SPECIAL   THERAPEUTICS.  207 


elementary  work ;  neither  do  we  yet  know  how  to  diagnosticate  cases 
with  sufficient  accuracy  to  enable  us  conscientiously  to  recommend  it. 

Notwithstanding  these  few  strictures  we  have  felt  obliged  to  make, 
we  say  again,  as  we  said  before,  that  Hartmann's  work  is,  on  the  whole, 
most  excellent  and  trustworthy. 

The  English  edition  reflects  great  credit  on  the  publisher,  paper,  illus- 
trations, and  type  being  all  equally  praiseworthy.  We  are  sorry  to  say 
that  the  translator  might  have  done  his  work  better.  In  not  a  few 
places  the  sense  is  not  the  same  in  the  English  as  in  the  German  work. 
Thus,  on  page  114  (English  edition)  the  following  sentence  occurs : 
"  Usually  in  cases  of  perforation  [i.  e.,  of  the  membrana  tympani,  Rev.], 
with  a  knitting-needle,  the  consequent  pain,  tinnitus,  dulness  of  hearing, 
and  perhaps  fainting  occur  only  at  intervals."  The  error  here  lies  in 
the  fact  that  in  translating  the  words  "  nur  vorubergehend,"  the  writer 
has  used  as  their  English  equivalent  "  only  at  intervals,"  whereas  the 
sentence  should  run  "  only  transient  .  .  .  occur."  We  have  no 
doubt  that  if  a  second  English  edition  should  be  required  the  translator 
will  correct  this  and  other  similar  mistakes  (of  which  we  regret  to  say 
there  are  not  a  few).  We  would  also  suggest  that  more  attention  should 
be  paid  to  English  composition.  The  following  may  be  a  literal  trans- 
lation, but  it  retains  too  much  of  the  German  idiom  (not  unmixed  with 
a  Scottish  element)  to  be  altogether  acceptable  to  the  taste  of  an  English 
reader :  "  Therefore  ought  we  always  to  open  the  antrum  freely  along 
with  the  neighboring  cells  "  (p.  190). 


Haxdbuch  der  Allgemeixex  uxd  Speciellex  Arzxeiverordxuxgs- 
lehee.  Auf  Grundlage  der  neuesten  Pharmacopoeen.  Bearbeitet  von 
Dr.  C.  A.  Ewald.  Elfte  neue  unigearbeitete  und  vermehrte  Auflage. 
Berlin :  Verlag  von  A.  Hirschwald,  1887. 

Haxdbook  of  Gexeral  axd  Special  Therapeutics.  By  Dr.  C.  A. 
Ewald. 

The  object  of  Professor  Ewald  in  writing  his  now  well-known  work 
was  for  the  purpose  of  providing  his  medical  brethren  with  a  book  on 
formulary,  rather  than  a  text-book,  on  the  use  of  drugs  in  disease.  Every 
page  teems  with  prescriptions,  and  the  text,  while  showing  a  widespread 
knowledge  of  therapeutical  literature,  is  cramped  and  dwarfed  in  the 
endeavor  to  introduce  a  multitude  of  formulae. 

The  pharmacological  literature  of  every  civilized  nation  has  been 
drawn  upon,  so  that  nearly  every  prescription  has  appended  to  it  the 
name  of  its  originator,  while  the  consideration  of  the  uses  and  actions 
of  the  drugs  has  been  taken  from  the  pharmacopoeias  of  all  nations 
possessing  an  official  work  on  medicaments.  The  very  fact  that  this 
book  has  reached  an  eleventh  edition  shows  us,  however,  that  empiricism 
is  as  rife  in  Germany  as  at  home,  and  that  a  very  large  class  of  prac- 
titioners of  medicine  still  treat  their  patients  by  the  shotgun  method 
rather  than  by  stern  reasoning  and  logic. 

As  a  work  on  formulary  Ewald's  book  certainly  distances  all  com- 


208 


EEVIEWS. 


petitors,  and  although  the  labor  involved  in  its  construction  must  have 
been  enormous,  the  author  certainly  cannot  complain  that  his  efforts 
have  not  been  appreciated.  H.  A.  H. 


Hip  Disease  in  Childhood,  with  Special  Beference  to  its  Treat- 
ment by  Excision.  By  G.  A.  Wright,  BA.,  M.B.  Oxon.,  F.E.C.S. 
Eng.,  Assistant  Surgeon  to  the  Manchester  Boyal  Infirmary ;  Lecturer  in 
Clinical  Surgery  in  the  Owens  College,  etc.  8vo.  pp.  239.  With  48  original 
woodcuts.    London  :  Longmans,  Green  &  Co.,  1887. 

In  noticing  this  monograph,  dealing  with  so  many  questions  which, 
despite  all  experience  and  research,  are  still  moot  points,  it  will  be  im- 
possible to  do  more  than  touch  upon  a  few  salient  ones. 

As  the  author  has  performed,  between  October  30,  1880,  and  July  8, 
1886,  one  hundred  excisions  of  the  hip,  we  are  warranted  in  concluding 
that  he  trusts  but  little  to  nature  in  morbus  coxa?.  A  very  fair  resume 
is  given  of  the  pathological  views  of  all  the  more  prominent  writers 
who  treat  of  hip  disease,  and  the  conclusion  is  arrived  at  "  that  all  cases 
of  true  chronic  hip  disease  are  truly  tuberculous."  The  chapter  on 
"  Symptoms  "  is  full,  but  we  can  only  note  that  swelling  of  the  inguinal 
glands  indicates  osteitis  of  the  pelvis  rather  than  the  femur  ;  that  "nearly 
every  case  of  chronic  disease  of  the  hip,"  if  examined  "  at  a  certain 
period  of  its  course,"  will  "  be  found  to  contain  pus ;  "  and  that  the  dis- 
appearance of  abscesses  is  sometimes  to  be  accounted  for  by  their 
discharge  through  the  rectum,  which  "  is  commoner  than  is  supposed." 
The  belief  is  expressed  "  that  chronic  hip  disease  begins  invariably,  or 
nearly  so,  as  an  ostitis,"  and  that  "  cases  of  true  hip  disease  rarely  re- 
cover without  entire  destruction  of  the  upper  epiphysis  of  the  femur, 
usually  accompanied  by  abscess,  and  always  result  in  shortening,  with 
more  or  less  deformity,  and  a  very  large  majority  die ;  very  few  reach 
adult  life."  .  .  .  When  the  following  sentences  are  read  it  will  be 
seen  exactly  what  the  author's  views  as  to  treatment  really  are :  "  I 
agree  that  abscesses  should  be  opened,  but  as  there  then  remains 
what  is  practically  a  sequestrum  as  the  source  of  the  abscess,  I  think 
it  should  be  removed — i.  e.,  the  upper  end  of  the  bone  excised  (except 
in  cases  of  residual  abscess.  .  .  .  )  ; "  in  other  words,  he  advises 
treatment  by  rest  and  extension,  but  if  an  absess  forms  despite  this,  excise 
in  all  cases.  Again,  "  treatment  short  of  excision  when  once  suppura- 
tion occurs,  is  useful  only  as  a  palliative,  or  a  means  of  temporizing." 
In  justice  to  the  author  we  must  say  that  although  he  has  excised  in 
about  one  case  out  of  every  six  seen,  he  believes  that  such  radical  treat- 
ment will  not  be  so  often  required  in  other  than  hospital  patients.  As 
to  the  method  of  operating,  he  prefers  to  saw  off  the  bone  in  situ  through 
the  trochanter,  and  then  disarticulate  the  fragment.  The  elastic  bandage 
is  thought  useful  in  the  after-treatment  where  there  is  much  thickening 
of  the  soft  parts,  or  the  sinuses  remain  "  flabby  and  sluggish."  The  mor- 
tality of  Mr.  Wright's  excisions,  he  contends,  amounts  to  only  three  per 
cent.,  explaining  two  other  deaths  by  a  preexistent  pyaemia.  Amputa- 


HOFMANN,  ULTZMANN,  ANALYSIS  OF   THE   URINE.  209 


tioD,  either  before  or  after  excision,  is  shown  to  be  more  applicable  than 
is  usually  taught,  and  the  implied  advice  is  given  that  even  with  exten- 
sive pelvic  disease  nearly  one-half  of  the  pelvis  may  and  should  be  re- 
moved after  a  preliminary  ligature  of  the  common  iliac  artery.  In  the 
appendix  are  given  the  history  of  a  number  of  cases  of  special  interest, 
and  a  very  full  bibliography  of  the  subject. 

Our  space  forbids  anything  like  an  analysis  of  Mr.  Wright's  work, 
which  certainly  advocates  the  most  heroic  treatment  of  this  lamentably 
frequent  disease.  Those  who  desire  to  study  hip  disease,  from  an  almost 
purely  operative  point  of  view,  should  read  this  book,  but  for  ourselves 
we  can  only  say  that,  being  not  quite  so  much  of  a  pessimist  as  Mr. 
Wright  evidently  is,  we  have  more  faith  in  conservative  treatment  than 
he  has,  and  would  warn  those  who  read  his  book  that  the  views  held  are 
so  extreme  as  to  demand  more  proof  than  he  has  adduced  in  support  of 
his  position.  C.  B.  N. 


Analysis  of  the  Urine,  with  Special  Reference  to  the  Diseases  of 
the  Genito-Urinary  Organs.  By  R.  B.  Hofmann,  Professor  in  the 
University  of  Gratz,  and  R.  Ultzmann,  Docent  in  the  University  of  Vienna. 
Translated  by  T.  Barton  Brune,  A.M.,  M.D.,  etc.,  and  H.  Holbrook 
Curtis,  Ph.B.,  M.D.,  etc.  Second  edition,  revised  and  enlarged.  8vo. 
pp.  310,  with  notes.    New  York :  D.  Appleton  &  Co.,  1886. 

In  the  Journal  for  January,  1880,  we  noticed  the  appearance  of  the 
first  edition  of  the  translation  of  Hofmann  and  Ultzmann's  admirable 
work  on  the  examination  of  the  urine,  and  expressed  an  opinion  of  the 
worth  of  the  original,  which  we  still  entertain.  The  present  edition 
embodies  the  advances  which  have  been  made  in  the  technique  of 
examination  of  the  urine  since  the  first  edition  was  prepared,  and  no 
small  part  of  this  work  has  been  contributed  by  the  translators.  An 
example  of  the  share  they  have  taken  in  bringing  the  work  up  to  date 
is  found  in  the  chapter  on  albumin,  which,  we  regret  to  see,  they  still 
call  "albumen."  In  doing  this,  they  translate  the  German  " Eiweiss " 
literally ;  but  it  is  of  some  importance  to  note  that  the  albumin  found 
in  urine  is  not  albumen  (egg-albumen). 

The  translators,  also,  use  the  word  "  cylinders  "  for  what  are  univer- 
sally known  in  English  and  American  books  as  "tube-casts."  This  we 
consider  an  error  of  judgment. 

We  might  multiply  examples  of  too  literal  translation  from  the 
German  in  this  work ;  but  we  are  happy  to  say  that  the  present  edition 
is  so  much  an  improvement  upon  its  predecessor  that  we  cannot  repeal 
our  former  comment  upon  the  familiarity  of  the  translators  with  the 
language  in  which  it  was  first  written.  On  the  contrary,  it  gives  as 
pleasure  to  note  that  many  of  the  lapses  contained  in  the  first  edition 
have  been  corrected  in  this  one,  and  to  commend  the  smoothness  which 
marks  it  in  general.  As  to  the  intrinsic  merits  of  the  book,  we  need  say 
little.  But  we  can  say  that  it  is  one  of  the  best  and  clearest  works  on 
the  examination  of  the  urine  with  which  we  arc  acquainted.  In  the 
part  devoted  to  the  clinical  application  of  its  teachings  it  is  except  ion- 
ally  good.  C.  W.  D. 

NO.  CLXXXV1I. — JULY,  1887.  14 


210 


EE  VIEWS. 


Die  Ursachlichen  Momenten  der  Augenmuskellahmungen  :  die 
Nicht-nuclear  Lahmungen.  Von  L.  Mauthner,  K.  K.  Universitats 
Prof,  in  Wien.    Wiesbaden,  1886. 

The  Causal  Conditions  of  Muscular  Paralysis  oe  the  Eye  :  Non- 
Nuclear  Paralysis.   By  Prof.  L.  Mauthner. 

In  the  number  of  this  journal  for  October,  1885,  we  noticed  the 
twelfth  instalment  of  Prof.  Mauthner's  clinical  exposition  of  eye  affec- 
tions, which  was  devoted  entirely  to  the  nuclear  paralyses  of  the  ocular 
muscles.  This,  the  thirteenth  number,  is  a  continuation  and  conclusion 
of  his  study  of  the  causes  of  ocular  paralyses,  and  is  given  to  the  cortical 
and  fascicular,  the  basal,  the  orbital,  and  peripheral  paralyses.  Together, 
the  two  constitute  by  far  the  most  thorough  and  elaborately  wrought- 
out  study  of  the  etiology  of  eye  paralyses  that  has  ever  been  published ; 
and  implying,  as  the  major  part  of  these  paralyses  do,  lesions  within  the 
cranial  cavity  and  a  direct  or  remote  manifestation  on  the  part  of  the 
other  divisions  of  the  nervous  system,  they  are  of  more  interest  and  im- 
portance to  the  physician  than  ophthalmological  studies  usually  are. 
We  therefore  direct  the  attention  of  students  of  the  nervous  system  to 
those  brochures,  and  predict  for  him  who  is  fortunate  enough  to  peruse 
them,  a  great  pleasure  in  following  out  the  keen  and  close  analysis  of 
symptoms  which  is  so  characteristic  of  the  writings  of  Prof.  Mauthner. 

Space  is  lacking  for  more  than  a  simple  citation  of  one  or  two  salient 
points.  In  speaking  of  paralysis  of  the  third  pair,  for  example,  if  the 
branches  to  the  iris  and  ciliary  muscles  remain  free  while  there  is  at 
the  same  time  contra-lateral  hemiplegia,  the  diagnosis  is  fascicular  paral- 
ysis ;  if,  however,  there  is  total  paralysis  of  the  third  pair,  it  argues  a 
circumscribed  alteration  at  the  peduncles  at  the  exit  of  the  oculomoto- 
rius,  or  a  change  extending  from  the  pedunculus  to  the  third  ventricle, 
or  the  pathological  change  may  be  only  basal. 

Relapsing  oculo-motor  paralysis  is  considered  in  great  detail,  and  an 
analysis  of  all  the  published  cases  given.  The  conclusion  from  a  study 
of  these  cases  is,  that  it  is  basal  in  its  character,  and  due  to  a  slowly 
developing  pachy-  or  lepto-meningitis.  He  also  points  out  as  a  matter  of 
the  highest  practical  interest,  that  double-sided  ophthalmoplegias  of  an 
intracranial  nature  can  be  developed  acutely  or  subacutely,  and  can 
disappear  in  a  relatively  short  time. 

Homonymous  hemianopia,  with  unilateral  nerve  paralysis,  can  come 
from  nuclear  or  basal  changes.  Amaurosis  of  the  corresponding  eye 
alone,  or  in  conjunction  with  temporal  hemianopia  of  the  second  eye, 
agues  a  basal  change  certainly.  The  orbital  and  peripheral  paralyses 
are  dealt  wTith  in  the  same  exhaustive  manner,  but  being  of  more  especial 
interest  to  the  ophthalmologist,  we  shall  not  dwell  upon  that  part,  sim- 
ply commending  them  for  the  force  and  clearness  with  which  the  various 
points  are  put.  S.  M.  B. 


QUARTERLY  SUMMARY 

or  THE 

PKOGKESS   OF  MEDICAL  SCIENCE. 


ANATOMY. 


UNDER  THE  CHARGE  OF 

GEORGE  D.  THANE,  M.E.C.S.  Eng., 

PROFESSOR  OF  ANATOMY  AT  UNIVERSITY  COLLEGE,  LONDON. 

The  Constitution  of  the  Restiform  Body. 

W.  Bechterew  has  studied  the  development  of  the  restiform  body  in  a 
series  of  fifteen  brains,  from  various  periods  of  foetal  life.  He  finds  that  this 
body  is  made  up  of  five  constituents,  which  are  enumerated  in  the  order  of 
acquiring  their  medullary  sheath :  1.  The  direct  cerebellar  tract  of  the  cord. 
2.  Fibres  springing  from  the  nucleus  of  the  funiculus  cunextus  of  the  same 
side.  3.  Fibres  springing  from  the  lateral  nucleus  of  the  same  side.  4. 
Fibres  issuing  from  the  nuclei  of  the  funiculi  graciles  of  both  sides ;  the  set 
derived  from  the  nucleus  of  the  same  side  ascend  to  the  restiform  body  as  the 
posterior  superficial  arcuate  fibres ;  while  those  springing  from  the  opposite 
nucleus  pass  forward  in  the  interolivary  layer  (olivenzuischenschichl),  and 
emerge  on  the  inner  side  of  and  through  the  pyramid,  as  well  as  between  the 
pyramid  and  the  olive,  and  form  the  anterior  superficial  arcuate  fibres.  5. 
Fibres  from  the  lower  olive  of  the  opposite  side. 

The  last  set  of  fibres  were  demonstrated  by  Meynert ;  but  they  do  not,  as 
assumed  by  Meynert  and  Wernicke,  form  a  continuation-  of  the  posterior 
columns  to  the  cerebellum.  They  compose,  with  a  tract  of  fibres  previously 
shown  by  Bechterew,  ascending  in  the  tegmentum,  a  system  which  unites  the 
cerebellum  with  the  base  of  the  cerebrum  through  the  lower  olive. 

Neither  the  formatio  reticularis  nor  the  pyramid  of  the  medulla  oblongata 
has  any  relation  to  the  restiform  body ;  nor  does  the  latter  receive  any  fibres 
from  the  fifth  and  eighth  nerves,  as  stated  by  Edinger.  The  auditory  nerve 
is  connected  to  the  cerebellum  by  a  special  bundle  which  ascends  in  the  inner 
part  of  the  middle  peduncle.  The  fifth  nerve  has  no  connection  at  all  with 
the  cerebellum. 

Within  the  cerebellum,  the  restiform  body  is  distributed  in  three  distinct 
bundles,  viz. :  1.  Containing  the  fibres  from  the  direct  cerebellar  tract  of  the 
cord,  from  the  nucleus  of  the  funiculus  cunextus,  and  from  the  lateral  nucleus 
passes  to  the  cortex  of  the  forepart  of  the  upper  worm ;  2.  Composed  of  the 
fibres  from  the  nuclei  of  the  funiculi  graciles,  to  the  middle  portion  of  the 


212 


PROGRESS  OF   MEDICAL  SCIENCE. 


upper  worm  on  the  same  side ;  and  3.  Comprising  the  fibres  from  the  opposite 
olive,  to  the  gray  substance  of  the  corpus  dentatum,  and  in  part,  perhaps,  to 
the  cortex  of  the  hemisphere. — Archiv  fur  Anatomic,  February,  1887. 

The  Morphology  of  the  Sacral  Plexus. 

It  is  by  no  means  an  unfrequent  occurrence  for  the  two  popliteal  nerves  to 
arise  separately  from  the  sacral  plexus;  and  in  that  case  the  external  (or 
peroneal)  nerve  generally  pierces  the  pyriformis  muscle,  the  lower  portion  of 
which,  therefore,  separates  this  from  the  more  deeply  placed  internal  nerve. 
But  when,  in  the  usual  arrangement,  these  nerves  are  united  for  a  certain  por- 
tion of  their  extent  in  a  great  sciatic  trunk,  the  latter  can  be  easily  divided 
into  its  two  constituents  by  dissecting  off  the  fibrous  sheath,  and  the  popliteal 
nerves  can  be  followed  upward  to  their  distinct  origins.  By  thus  separating 
the  nerves,  A.  M.  Paterson  is  enabled  to  show  that  the  construction  of  the 
sacral  plexus  agrees  in  principle  with  that  of  the  brachial,  and  to  throw  light 
upon  the  morphology  of  the  nerves  of  the  limbs. 

The  nerves  proceeding  to  the  popliteal  trunks  are  each  divided  into  an 
anterior  and  a  posterior  branch.  By  the  union  of  the  posterior  branches  of 
the  descending  offset  from  the  fourth  lumbar,  of  the  fifth  lumbar,  and  of  the 
first  and  second  sacral  nerves,  the  external  popliteal  is  formed;  and  the 
anterior  branches  of  the  same  nerves,  together  with  an  offset  from  the  third 
sacral,  constitute  the  roots  of  the  internal  popliteal.  The  gluteal  nerves  are 
offsets  of  the  posterior  divisions,  or  external  popliteal  roots,  the  superior 
arising  from  the  fourth  and  fifth  lumbar  and  the  first  sacral  nerves,  and  the 
inferior  from  the  first  and  second  sacral  nerves.  The  small  sciatic  arises  from 
the  back  of  the  second  and  third,  and  the  pudic  from  the  second,  third,  and 
fourth  sacral  nerves.  The  branch  to  the  obturator  internus  springs  from  the 
second  and  third  sacral  nerves,  that  to  the  quadratus  from  the  beginning  of 
the  internal  popliteal  nerve,  and  the  nerve  of  the  pyriformis  from  the  posterior 
branch  of  the  second  sacral.  The  branches  to  the  hamstring  muscles  are 
given  off  from  the  internal  popliteal  nerve. 

Like  the  popliteal  nerves,  the  obturator  is  formed  by  anterior  branches,  and 
the  anterior  crural  by  posterior  branches  of  the  second,  third,  and  fourth 
lumbar  nerves. 

There  are  thus  two  chief  sets  of  nerves  passing  to  the  lower  limb — one  com- 
prising the  anterior  crural,  external  popliteal  and  gluteal,  springing  from 
posterior  branches,  and  distributed  in  the  original  extensor  aspect ;  and  the 
other,  consisting  of  the  obturator  and  internal  popliteal,  springing  from 
anterior  branches,  and  passing  to  the  flexor  aspect  of  the  limb.  From  this  it 
is  inferred  that  in  the  primitive  condition  of  the  limbs  the  nerves  passing  into 
them  are  divided  into  dorsal  and  ventral  branches,  which  supply  the  corre- 
sponding surfaces,  and  that  indications  of  this  arrangement  are  retained  in 
the  mode  of  origin  of  the  nerves  and  their  distribution  to  the  structures  of  the 
limb. — Journal  of  Anatomy,  April,  1887. 

On  the  Bursa  Pharyngea. 

The  name  bursa  pharyngea  was  given  by  F.  J.  C.  Mayer  to  a  small  pouch 
of  the  mucous  membrane  described  by  him,  and  afterward  more  fully  by 


ANATOMY. 


213 


Luschka,  as  projecting  from  the  upper  end  of  the  posterior  wall  of  the  pharynx. 
According  to  Luschka,  this  pouch  may  attain  a  length  of  15  mm.  and  a  breadth 
of  6  mm. ;  it  lies  behind  the  adenoid  tissue,  constituting  the  pharyngeal  ton- 
sil ;  and  its  blind  upper  extremity  is  connected  with  the  basilar  process  of  the 
occipital  bone.  The  normal  existence  of  such  a  pouch  has  been  denied  by 
Ganghofner  and  Trautmann,  who  found  only  a  small  depression  of  the  mucous 
membrane  at  the  spot  indicated;  and  for  this,  Ganghofner  proposed  the  name 
of  recessus  pharyngeus  medius.  On  the  other  hand,  Tornwald  states  that  a 
sac  or  canal  is  present  in  the  great  majority  of  cases. 

In  view  of  these  conflicting  statements,  Schwabach  examined  this  region 
in  53  subjects,  28  being  infants  or  young  children,  in  whom  alone  a  normal 
pharyngeal  tonsil  is  to  be  seen,  and  in  no  case  did  he  find  a  bursa  as  described 
by  Luschka,  while  Ganghofner's  account  is  fully  confirmed. 

In  the  young  subject  the  pharyngeal  tonsil  is  divided  by  fissures  into 
ridges  of  variable  height,  which  are  directed  for  the  most  part  more  or  less 
obliquely.  On  most  preparations  two  ridges  close  to  the  middle  line  are  more 
prominent  than  the  rest,  and  enclose  a  central  furrow  of  corresponding  depth. 
In  some  cases,  however,  there  is  a  median  ridge  dividing  this  furrow.  At  the 
back  of  the  median  furrow  or  ridge  there  is  generally  a  slight  depression 
about  the  size  of  a  pin's  head,  and  in  four  instances  it  took  the  form  of  a 
recess  2  or  3  mm.  deep.  A  small  transverse  fold  of  the  mucous  membrane 
sometimes  divides  this  depression  into  anterior  and  posterior  parts,  or  separates 
it  from  the  groove.  In  several  cases  there  was  no  trace  at  all  of  this  hollow; 
and  in  no  instance  was  it  more  than  a  superficial  depression  of  the  mucous 
membrane  devoid  of  any  connection  with  the  bone. 

In  the  adult  there  are  usually  but  few  indications  of  the  original  conforma- 
tion of  the  tonsil,  the  median  cleft  and  its  bounding  ridges  being  the  parts 
most  frequently  retained;  but  even  when  all  the  ridges  have  disappeared,  the 
furrow  is  still  represented  by  a  slight  fossa  or  a  canal  bridged  over  by  the 
mucous  membrane.  Such  bridges  of  mucous  membrane  are  of  frequent  occur- 
rence on  the  pharyngeal  tonsil,  on  the  roof  of  the  pharynx,  and  in  the  recess 
of  Rosenmiiller ;  and  the  cavities  may  also  be  completely  enclosed  by  mucous 
membrane  giving  rise  to  cysts.  The  descriptions  of  the  bursa  given  by 
Luschka  and  Tornwald  are  regarded  as  relating  to  pathological  states. 

It  has  been  shown  by  Dursy  and  Froriep  that  the  recessus  pharyngeus 
medius  is  not  connected  with  the  formation  of  the  hypophysis  cerebri ;  and 
the  latter  writer  considers  it  probable  that  it  is  related  to  the  retropharyngeal 
chorda.  On  this  point  Schwabach  promises  a  further  communication  dealing 
with  researches  now  in  progress. — Archiv  fur  microskop.  Anat.,  Feb.  1887. 

On  the  Closure  of  the  Cardiac  Orifice  of  the  Stomach. 

It  was  observed  by  Braune  that  water  injected  in  considerable  quantity  into 
the  stomach  through  the  oesophagus,  with  the  body  in  a  horizontal  position, 
does  not  flow  out  again,  although  no  ligature  is  applied.  To  explain  this 
phenomenon,  A.  v.  Gubaroff,  working  in  Braune's  laboratory,  investigated 
the  mechanism  by  which  the  cardiac  orifice  is  closed.  In  part  the  closure  is 
to  be  explained  by  the  action  of  the  diaphragm,  the  fibres  of  which  form  a 
sphincter  around  the  oesophageal  opening;  but  it  is  mainly  duo  to  a  valve- 


214 


PROGRESS  OF   MEDICAL  SCIENCE. 


like  arrangement  dependent  on  the  relation  of  the  ending  of  the  oesophagus 
to  the  stomach. 

In  a  frozen  section,  the  stomach  being  distended,  the  lower  end  of  the 
oesophagus  is  seen  to  be  bent  sharply  to  the  left,  the  fundus  of  the  stomach 
extends  upward  considerably  beyond  the  cardia,  and  the  left  margin  of  the 
latter  projects  toward  the  right  or  lower  border  in  the  form  of  a  rounded  edge 
or  fold  containing  a  thick  bundle  of  fibres  of  the  diaphragm.  When  water  is 
injected  under  a  low  pressure  into  the  stomach  from  the  duodeno-jejunal 
flexure,  it  does  not  flow  into  the  oesophagus  so  long  as  the  parts  are  in  their 
natural  position ;  but  if  the  stomach  is  drawn  downward,  so  as  to  stretch  the 
angle  between  the  oesophagus  and  the  fundus,  the  fluid  enters  the  gullet.  In 
the  child  the  oesophagus  takes  a  straighter  course  to  the  stomach,  and  the 
facility  with  which  food  regurgitates  in  the  infant  is  thus  accounted  for. 
Perhaps  the  varying  readiness  with  which  vomiting  occurs  in  different  people 
is  to  be  attributed  to  the  degree  of  development  of  this  valvular  structure. — 
Archiv  fur  Anatomie,  February,  1887. 

On  the  Position  of  the  Duodenum,  of  the  Ileocolic  Junction, 
and  of  the  sigmoid  flexure. 

P.  Schiefferdeckee,  publishes  observations  on  the  variations  in  position 
of  certain  parts  of  the  intestinal  canal,  collected  during  the  dissection  of  about 
jtwo  hundred  bodies  in  Rostock  and  Gottingen.  In  the  duodenum  the  only 
noteworthy  class  of  deviations  relates  to  the  length  of  the  second  part,  and 
the  consequent  level  at  which  the  third  part  crosses  the  spine.  This  may  be 
as  high  as  the  disk  between  the  second  and  third  lumbar,  or  as  low  as  the  top 
of  the  fifth  lumbar  vertebra.  The  situation  of  the  duodeno-jejunal  flexure  is 
very  constant. 

The  opening  of  the  ileum  into  the  large  intestine  is  most  frequently  placed 
on  a  level  with,  and  a  little  to  the  outer  side  of  the  right  sacroiliac  articulation. 
A  lower  position  is  often  met  with ;  and  occasionally  it  lies  in  the  cavity  of 
the  true  pelvis.  Only  two  cases  were  met  with  in  which  the  ending  of  the 
ileum  had  a  markedly  higher  position  than  usual ;  in  one  it  was  opposite  the 
third  lumbar  vertebra ;  and  in  the  other  in  front  of  the  kidney,  on  a  level 
with  the  second  lumbar  vertebra,  so  that  there  was  practically  no  ascending 
colon.  In  both  these  instances  the  other  abdominal  organs  were  normal,  and 
the  testicles  were  in  the  scrotum. 

The  position  of  the  sigmoid  flexure  is  very  variable,  and  the  different  forms 
are  collected  into  four  groups,  as  follows : 

I.  The  flexure  lies  to  the  inner  side  of  the  descending  colon. 

a.  The  loop  hangs  down  in  the  pelvic  cavity.  This  is  regarded  as  the  normal 
form  as  shown  by  the  developmental  history,  and  by  its  being  mechanically 
the  most  natural. 

b.  The  loop  is  turned  upward  and  applied  to  the  posterior  abdominal  wall. 
In  one  extreme  case  the  loop  ascended  on  the  side  of  the  spine  to  the  left 
kidney,  being  fixed  here  by  the  peritoneum  ;  and  in  another  the  loop,  having 
a  free  meso-sigmoideum,  crossed  the  middle  line  and  reached  the  right  iliac 
fossa,  where  it  touched  the  caecum.  Between  these  extremes  all  intermediate 
forms  occur. 


ANATOMY. 


215 


c.  The  loop  is  directed  upward,  but  other  parts  of  intestine  intervene  between 
it  and  the  posterior  wrall ;  and  it  may  come  in  contact  to  a  greater  or  less  extent 
with  the  anterior  wall.    These  cases  are  very  frequent. 

II.  The  flexure  lies  to  the  outer  side  of  the  descending  colon.  Only  one 
example  of  this  condition  was  met  with;  and  it  is  probable  that  it  differs  in 
kind  from  the  foregoing  groups,  being  not  merely  an  irregular  position  of  an 
identical  loop,  but  a  loop  formed  in  the  intestine  immediately  above  the 
situation  of  the  normal  one  which  is  undeveloped. — Arch,  f  ar  Anat.,  Feb.  1887. 

On  the  Relative  Length  of  the  Fingers  and  Toes. 

W.  Braune  contributes  some  interesting  observations  on  the  form  of  the 
hand  and  foot  in  a  paper  contained  in  the  volume  recently  dedicated  to  C. 
Ludwig  by  his  pupils.  It  is  well  known  that  in  works  of  art  the  hand  is  gen- 
erally represented  with  the  index  finger  more  prominent  than  the  ring  finger, 
whereas  in  nature  such  a  form  is  only  met  with  exceptionally.  But  the 
attempt  to  estimate  the  length  of  the  several  fingers  by  inspecting  the  hand, 
or  even  by  tracing  the  outline  on  paper,  after  Ecker's  method,  is  fallacious  ; 
and  only  direct  measurements  of  the  bones  yield  trustworthy  results.  Braune 
gives  a  table  of  the  length  of  the  metacarpal  bones  and  phalanges  in  93  hands, 
in  39  of  which  the  bones  were  still  united  by  their  ligaments,  while  the  remain- 
ing 54  were  artificially  mounted.  In  the  following  statistics  the  latter  group 
is  not  taken  into  account,  since  there  may  be  doubt  as  to  the  proper  position 
of  some  of  the  bones. 

Taking  the  metacarpal  bones  and  phalanges  together,  the  index  finger  is 
longer  than  the  ring  in  27,  and  shorter  in  10,  while  the  two  are  equal  in  2. 
In  all  the  second  metacarpal  bone  is  longer  than  the  fourth,  and  the  pha- 
langes of  the  ring  finger  are  longer  than  those  of  the  index  finger.  The  first 
phalanx  of  the  index  is  the  longer  in  33,  of  the  ring  finger  in  3,  and  the  two 
are  equal  in  3.  The  middle  phalanx  of  the  ring  finger  is  the  longer  in  all. 
The  last  phalanx  of  the  ring  finger  is  the  longer  in  34,  that  of  the  index  in  4, 
and  in  one  case  the  two  are  equal. 

The  greater  length  of  the  index  finger  as  a  whole  thus  depends  entirely  (as 
was  pointed  out  by  J.  Marshall,  in  his  Anatomy  for  Artists,  1887)  on  the  length 
of  the  metacarpal  bone.  The  greater  prominence  of  the  ring  finger  usually 
seen  in  the  hand  is  attributed  by  Braune  to  a  lateral  inclination  of  the  fingers 
to  the  ulnar  side,  due  primarily  to  the  oblique  pull  of  the  flexor  muscles.  The 
hand  with  a  longer  index  finger  is  the  higher  form,  not  simply  by  reason  of 
contrast  with  the  hand  of  the  ape,  but  because  it  is  thereby  better  fitted  for 
the  special  work  of  man. 

In  the  same  way,  the  foot  is  generally  represented  by  artists  with  the  second 
toe  projecting  beyond  the  first,  but  in  the  natural  foot  the  great  toe  almost 
always  appears  the  most  prominent.  This  appearance  is,  however,  a  result  of 
the  flexion  of  the  second  toe,  caused  by  the  pressure  of  the  shoe  ;  and  if  it  be 
carefully  straightened,  the  second  toe  is  generally  found  to  be  the  longest. 
Of  37  students  of  his  class,  Braune  found  the  second  toe  longer  in  26,  the  great 
toe  longer  in  6,  and  the  two  of  equal  length  in  5.  In  children  and  people 
who  go  barefooted  the  second  toe  is  the  longest. 

The  characteristic  forms  of  the  hand,  with  its  longest  third  digit,  and  of  the 


216 


PKOGRESS  OF  MEDICAL  SCIENCE. 


foot,  with  its  longest  second  toe,  are  evident  at  a  very  early  period  in  the 
foetus.  Whether  there  is  any  variation  in  the  proportions  referred  to  among 
different  races  of  men,  as  assumed  by  Ecker,  Kollmann,  and  Park  Harrison, 
the  material  at  present  available  is  insufficient  to  show. 


PHYSIOLOGY. 


UNDER  THE  CHARGE  OF 

GERALD  F.  YEO,  M.D., 

PROFESSOR  OF  PHYSIOLOGY  AT  KING'S  COLLEGE,  LONDON. 


Visual  Centres  of  Cerebral  Cortex. 

Prof.  Sigm.  Exner  and  Dr.  Joseph  Paneth  found  defective  vision, 
lasting  some  weeks  after  the  operation,  to  follow  removal  of  parts  of  the 
sigmoid  gyrus  of  the  dog.  This  was  observed  in  five  out  of  six  animals.  In 
that  in  which  there  was  no  defect  of  vision  the  lesion  was  just  in  front  of 
Munk's  centres.  They  therefore  agree  with  those  authors  who  deny  that  the 
visual  functions  are  to  be  restricted  to  the  posterior  parts  of  the  convexity  of 
the  brain. — Pfluger's  Archiv,  Bd.  xl.  p.  62. 

Irritability  of  the  Various  Layers  of  the  Cerebral  Cortex. 

Drs.  Ernst  Asch  and  Alfred  Neisser  experimented  on  rabbits  to 
determine  whether  gray  surface  tissue  or  the  underlying  white  substance  of 
the  motor  regions  of  the  brain  be  the  more  easily  excited  by  electric  stimula- 
tion. They  conclude  that  in  the  track  from  the  surface  to  the  deeper  parts 
of  the  brain  there  exists  a  point  the  stimulation  of  which  is  followed  by  much 
more  active  movements  than  if  any  other  part  of  the  path  of  the  impulse  be 
similarly  stimulated.  This  point  is  the  boundary  between  the  gray  and  white 
substance,  and  most  probably  it  really  is  the  innermost  layer  of  the  gray 
matter.  With  weak  stimulations,  the  electrodes  piercing  the  gray  matter,  the 
authors  frequently  found  movement  of  the  limbs  on  the  same  side  of  the  body 
as  the  stimulus  was  applied  to  the  brain. — Pfliiger's  Archiv,  Bd.  xl.  p.  191. 

Intracardiac  Pressure. 

J.  Magini  estimates  the  variations  in  the  blood-pressure  within  the  heart 
of  dogs  by  means  of  a  special  trocar  pushed  through  the  apex.  The  position 
and  surroundings  of  the  organ  were  but  little  disturbed  by  the  operation, 
which  was  borne  well  by  the  animals,  so  that  the  investigation  could  be  con- 
tinued sometimes  for  an  hour.  Only  twice  in  twenty-one  operations  did 
insurmountable  complication  arise.  The  trocar  was  connected  with  a  man- 
ometer and  cardiographic  apparatus  by  means  of  a  thick-walled  caoutchouc 
tube  filled  with  soda  solution.  The  action  of  the  valves  thus  escaped  the 
interference  with  their  function  inseparable  from  Marey's  mode  of  procedure. 


PHYSIOLOGY. 


217 


The  pressures  were  generally  rather  higher  than  those  found  by  other 
observers,  and  the  curves  free  from  the  secondary  variations  which  are  so 
marked  on  Marey's  tracings.  A  negative  pressure  was  found  in  the  peri- 
cardium equal  to  thirty  mm.  of  mercury. — Arch.  Ital.  de  Biologie,  t.  viii. 
fasc.  i.  p.  125. 

The  Union  of  Carbonic  Acid  with  Haemoglobin. 

By  comparing  the  amount  of  C02  taken  up  by  water — which  follows  Henry's 
law — with  that  taken  up  by  solutions  of  haemoglobin,  Christian  Bohr  shows 
that  considerable  volumes  of  C02  may  be  made  to  unite  with  the  coloring 
matter  of  the  blood.  One  gramme  of  pure  haemoglobin  combines  with  about 
3.5  c.  c.  C02  at  a  pressure  of  120  mm. — i.  e.,  more  than  double  the  quantity  of 
oxygen  that  can  be  taken  up.  The  combination  is  readily  dissociated,  for  the 
quantity  existing  in  the  solution  diminishes  rapidly  as  the  pressure  is  lowered. 
The  maximum  absorption  is  reached  within  the  degree  of  pressure  named 
above.  Stronger  solutions  take  up  less  per  unit  of  haemoglobin  than  weak 
solutions.  No  decomposition  of  the  haemoglobin  occurred. — Beitrllge  zur 
Physiologie,  C.  Ludwig  gewidmet,  1887,  p.  164. 

The  Coagulation  of  the  Blood. 

L.  C.  Wooldridge  obtains  blood  from  a  dog  immediately  after  the  injec- 
tion of  peptone,  which  does  not  undergo  coagulation,  though  kept  till  it 
decomposes.  In  the  clear  plasma  separated  from  this  by  means  of  the 
centrifugal  machine,  two  complex  bodies  can  be  shown  to  exist,  which  are 
both  coagulable,  and  by  whose  inter-action  fibrin  is  produced.  He  names 
them  A.  and  B.  fibrinogen,  and  supposes  them  to  be  a  mixture  or  combination 
of  albumen  with  lecithin.  The  A.  fibrinogen  can  be  precipitated  from  the 
clear  plasma  by  cooling.  It  appears  as  small,  round,  colorless  masses  which 
readily  combine  to  form  a  fibrinous  material.  In  the  presence  of  this  body 
the  plasma  is  easily  made  to  coagulate,  the  existence  of  fibrin  ferment  having 
apparently  no  influence.  If  the  A.  fibrinogen  be  removed,  the  B.  fibrinogen 
will  not  coagulate  without  the  addition  of  some  substance  containing  lecithin. 
B.  fibrinogen,  therefore,  cannot  be  the  same  body  as  Hammarsten's  fibrinogen, 
since  the  addition  of  fibrin  ferment  does  not  induce  its  coagulation ;  but  by 
repeated  precipitation  with  acid  and  resolution  in  weak  alkalies,  it  assumes 
the  properties  of  that  body.  The  clear  plasma,  freed  from  all  form  elements 
by  the  centrifugal  machine,  contains  all  the  ingredients  necessary  for  spon- 
taneous coagulation.  The  ferment  which  appears  during  coagulation  is  said 
to  be  the  result  and  not  the  cause  of  the  clotting,  which  depends  upon  some 
transfer  of  lecithin  taking  place  from  one  kind  of  fibrinogen  to  the  other. 
Other  kinds  of  fibrinogen  are  said  to  exist  in  the  tissues  of  the  body  which 
can  cause  coagulation  either  within  or  without  the  bloodvessels. — Beitrage 
zur  Physiologie,  C.  Ludwig  gewidmet,  1887,  p.  221. 


218 


PROGRESS  OF   MEDICAL  SCIENCE. 


MATERIA  MEDICA,   THERAPEUTICS,  AND 
PHARMACOLOGY. 


UNDER  THE  CHARGE  OF 

EOBERTS  BAETHOLOW,  M.D.,  LL.DV 

PROFESSOR  OF  MATERIA  MEDICA,  GENERAL  THERAPEUTICS,  AND  HYGIENE  IN 
THE  JEFFERSON  MEDICAL  COLLEGE,  PHILADELPHIA. 


ACETANILID  (ANTIFEBRIN). 

This  promising  contribution  to  our  therapeutical  resources  has  recently  been 
the  subject  of  an  elaborate  investigation  by  Weill  {Bull.  Gen.  de  Th'erap., 
Feb.  28,  1887).  He  arrives  at  the  following  conclusions  in  regard  to  its  phys- 
iological actions  :  It  acts  especially  on  the  nervous  system,  and  after  a  period 
of  excitation  is  followed  by  depression  and  collapse ;  it  induces  general  anaes- 
thesia and  analgesia ;  it  causes  a  notable  increase  in  the  intravascular  blood- 
pressure  by  contracting  the  peripheral  arterioles ;  it  lowers  the  central  and 
peripheric  temperature,  and  in  a  toxic  quantity  seriously  impairs  the  compo- 
sition of  the  blood,  changing  haemoglobin  into  methasmoglobin. 

On  the  foregoing  conclusions  respecting  the  physiological  actions  of  acetani- 
lid,  Weill  bases  the  therapeutical  applications.  He  has  formulated  the  fol- 
lowing opinions  as  to  its  therapeutical  uses : 

Acetanilid  is  an  active  febrifuge.  It  has  the  highest  utility  in  almost  all 
diseases  of  which  the  one  symptom  to  be  relieved  is  elevated  temperature. 

It  acts  efficiently  in  all  nervous  affections  characterized  by  a  morbid  excita- 
bility of  the  reflex  functions — as,  for  example,  epilepsy. 

It  does  not  increase  but  rather  diminishes  the  flow  of  urine. 

Habit  is  set  up  by  uninterrupted  and  prolonged  administration. 

Acetanilid,  as  antifebrin,  has  also  been  the  subject  of  investigation  by 
Prof.  Lepine,  who  enlisted  Prof.  Charcot  in  its  clinical  study.  As  a  remedy 
for  the  pains  of  locomotor  ataxia,  and  for  the  trembling  of  sclerosis,  it  was 
found  to  relieve  many,  and  to  remove  the  symptoms  entirely  in  a  few.  Hav- 
ing the  power  to  diminish  the  reflex  excitability  of  the  spinal  cord,  it  was  also 
used  in  cases  of  epilepsy  with  considerable  success. 

Grunneberg  (Berl.  Min.  Wochenschrift,  p.  849,  1886)  reports  the  result  of 
his  use  of  antifebrin  in  typhoid.  He  finds  it  very  effective  when  a  con- 
siderable reduction  of  temperature  is  to  be  made.  Although  it  may  cause 
profuse  sweats  and  severe  chills  preceding  the  rise  of  temperature,  the 
action,  for  the  most  part,  is  free  from  unpleasant  symptoms.  He  has  given 
2  grammes  (3ss)  a  day  without  inconvenience,  but  50  centigrammes  (8  grains) 
have  proved  a  sufficient  quantity  to  reduce  fever. 

Dujardhst-Beaumetz  (Bull.  Gen.  de  Th'erap.,  March  30,  1887)  has  also 
made  a  clinical  investigation  of  acetanilid  in  continuation  of  the  observations 
of  Weill.  As  a  febrifuge  he  does  not  regard  it  as  an  important  contribution 
to  our  resources  in  this  respect,  and  holds  that  it  is  much  inferior  to  antipyrin 
for  this  purpose.  It  is  in  respect  to  its  action. on  the  nervous  system  that  he 
commends  its  use.  It  is  a  remarkable  fact  that  acetanilid  does  not  influence 
temperature  when  administered  in  the  apyretic  stage,  but  during  the  height 


MATERIA   MEDICA   AND  THERAPEUTICS. 


219 


of  the  febrile  exacerbation,  even  in  moderate  doses,  it  makes  a  considerable 
impression  on  the  pyrexia,  reducing  fever  heat  several  degrees. 

Dujardin-Beauinetz  has  never  exceeded  3  grammes  (46  grains),  and  usually 
gives  no  more  than  three  or  four  doses  of  50  centigrammes  each  (8  grains)  in 
the  course  of  twenty-four  hours.  He  has  employed  it  for  the  relief  of  three 
conditions,  namely :  for  pain  in  general,  for  the  pains  of  locomotor  ataxia, 
and  for  epilepsy. 

In  facial  neuralgia  it  is  inferior  to  aconite,  but  when  structural  alterations 
are  taking  place  in  the  nerve,  as  in  neuritis  of  the  optic,  acetanilid  is  supe- 
rior to  all  other  remedies.  In  muscular  rheumatism  and  neuralgia,  and  in 
neuralgia  of  the  articulations,  he  has  found  it  superior  to  the  salicylates. 
Also,  in  the  flying  pains  of  tabes  it  seems  to  be  peculiarly  effective.  Some- 
times the  effects  are  lasting,  but  in  other  cases  the  remedy  loses  its  influence 
after  long-continued  use. 

In  epilepsy  Dr.  Dujardin-Beauinetz  finds  acetanilid  a  useful  remedy.  Eec- 
ognizing  the  uncertainty  which  must  attend  the  exhibition  of  a  new  remedy 
in  this  malady,  so  much  influenced  by  mental  impressions,  a  degree  of  reserve 
is  necessary  in  accepting  favorable  conclusions.  In  his  own  hands  and  in  the 
experiences  of  others,  especially  of  Prof.  Grasset,  of  Montpelier,  some  remark- 
able results  have  been  obtained.  With  due  reserve,  and  making  allowances 
for  error,  there  is  yet  sufficient  evidence  to  show  that  acetanilid  is  a  valuable 
addition  to  the  remedies  now  employed  in  the  treatment  of  epilepsy. 

We  add  to  the  foregoing  observations  on  acetanilid,  or  antifebrin,  some 
studies  of  its  therapeutical  action  made  by  H.  Eisenhart  in  Ziemssen's 
Clinic,  which  appear  in  the  Centralblatt  fur  die  gesammte  Therapie  for  April, 
1887.  Eisenhart  reports  on  thirty  cases  of  disease,  including  typhoid, 
acute  rheumatism,  pneumonia,  some  eruptive  fevers,  and  other  febrile  disor- 
ders. The  doses  usually  administered  ranged  from  four  to  eight  grains.  The 
effects  are  observed  in  about  two  hours,  and  the  reduction  of  temperature 
amounts  to  1°  to  4°,  the  maximum  impression  occurring  in  three  to  four  hours. 
The  normal  temperature  is  little,  if  at  all,  affected  by  it,  and  hence,  as  has 
been  observed  by  others,  it  should  not  be  administered  in  the  apyretic  stage, 
but  rather  at  the  time  of  greatest  heat.  The  duration  of  the  antipyretic 
action  ranges  from  four  to  fourteen  hours.  As  is  the  case  with  antipyrin, 
antifebrin  causes  profuse  sweating ;  but  it  is  well  borne,  does  not  cause  nausea 
or  vomiting,  and  is  readily  taken. 

In  acute  rheumatism,  as  compared  with  antipyrin,  Dr.  Eisenhart  finds  it 
inferior,  and  it  is  also  less  curative  than  the  salicylates;  but  he  admits  that  it 
is  a  valuable  antipyretic  in  general,  and  especially  in  typhoid.  He  expresses 
the  conviction  that  the  course  of  typhoid  is  rendered  milder  and  its  duration 
lessened  by  the  administration  of  antifebrin. 

Antiseptic  Hypodermatic  Injections. 

So  much  has  been  published  of  late  on  this  important  subject  that  our 
readers  may  desire  more  exact  information  than  has  hitherto  been  furnished. 
The  oil  of  vaseline  which  is  used  as  the  vehicle  is  obtained  better  from  Rus- 
sian petroleum.  It  is  described  by  Dr.  Ley,  who  pursued  his  investigation 
in  the  laboratory  of  Dujardin-Beaumetz  {Bull.  Gen.  de  Therup.,  March  30, 


220 


PROGRESS  OF   MEDICAL  SCIENCE. 


1887),  as  a  colorless,  inodorous,  tasteless,  oily  fluid,  neutral  in  reaction,  and  of 
a  density  varying  between  0.820  and  0.880.  It  causes  no  pain  or  induration 
when  thrown  under  the  skin.  It  dissolves  the  essential  oils  in  equal  parts, 
and  such  substances  as  iodine,  bromine,  sulphide  of  hydrogen,  carbolic  acid, 
iodoform,  iodol,  sulphide  of  carbon,  and  by  some  special  manipulation,  a  large 
number  of  the  alkaloids,  as  morphine  and  cocaine,  in  varying  proportions. 
When  thrown  under  the  skin,  oil  of  vaseline  diffuses  rapidly,  and  as  quickly 
conveys  the  medicaments  incorporated  with  it,  through  the  system. 

The  clinical  studies  were  made  in  the  wards  of  Dujardin-Beaumetz  in  the 
Cochin  Hospital,  and  the  results  derived  from  various  agents  used  in  this 
way  are  set  forth  in  the  communication  from  which  we  now  quote.  The  solu- 
tion of  iodine  gives  some  admirable  results  in  cases  of  emphysema  and  asthma 
and  bronchial  catarrh;  the  cough  diminishes,  the  expectoration  lessens,  the 
sense  of  oppression  ceases,  the  appetite  is  restored,  and  sleep  is  again  enjoyed. 
Solutions  of  carbolic  acid  and  eucalyptol  have  been  tried  in  a  great  many 
cases  of  chronic  bronchitis  and  pulmonary  tuberculosis.  In  some  examples 
of  the  latter  the  injections  caused  too  much  excitement  and  fever  to  be  per- 
severed in  ;  but  in  those  of  a  chronic  and  subdued  character,  with  little  fever, 
eucalyptol  had  good  effects,  diminishing  the  cough  and  expectoration,  modi- 
fying the  sputa,  lessening  the  sweats,  and  restoring  sleep  and  appetite ;  but  it 
was  much  less  useful  and  sometimes  injurious  in  more  acute  cases,  more  nearly 
approaching  the  type  of  phthisis  florida. 

The  solutions  of  carbolic  acid  administered  subcutaneously,  and  the  same 
combined  with  iodine,  produced  surprising  results.  At  the  outset,  however, 
the  progress  was  slow,  but  the  improvement  continued,  and  even  in  unfavor- 
able cases  the  results  have  been  highly  satisfactory — for  not  only  in  respect 
to  the  rational  signs  of  phthisis  has  the  most  marked  improvement  taken 
place,  but  the  bacillus  is  gradually  made  to  disappear. 

Dr.  Ley  concludes  as  follow  :  The  pure  mineral  oil,  now  known  as  the  oil 
of  medicinal  vaseline,  is  a  very  useful  vehicle  for  making  solutions  to  be 
employed  subcutaneously.  The  oil  of  arachides  (?)  is,  of  all  vegetable  oils, 
the  best  adapted  to  the  same  purpose. 

Of  the  medicaments  subjected  to  experimental  trials,  iodine  and  carbolic 
acid  occupied  the  first  place,  eucalyptol  and  sulphide  of  carbon  coming  after. 

The  injections  containing  eucalyptol  had  the  strength  of  20  to  50  per  100. 
The  medium  dose  is  60  to  75  centigrammes  (about  10  to  15  grains).  After 
fifteen  to  twenty  days  use  of  the  remedy,  an  intermission  of  a  few  days  is 
desirable,  or  for  the  eucalyptol  some  corresponding  remedy  may  be  substi- 
tuted, such  as  terpinol,  terebinthin,  etc. 

Eucalyptol  administered  hypodermatically  is  quickly  absorbed,  and  is 
eliminated  largely  by  the  lungs,  but  some  accumulation  takes  place  in  the 
system,  a  fact  that  must  be  kept  in  mind.  It  does  not  affect  the  fever  of  pul- 
monary tuberculosis,  but  acts  on  the  bronchial  mucous  membrane,  and  exerts 
a  distinctly  curative  influence  in  the  catarrhal  affections  of  the  bronchi.  Its 
action  is  local,  but  it  does  not  affect  tubercle.  Carbolic  acid  is  a  more  efficient 
antiseptic,  and  when  combined  with  iodine,  has  a  very  pronounced  effect  on 
bronchial  catarrh. 

In  grave  cases,  better  results  are  had  from  the  administration  of  iodine  and 
carbolic  acid,  the  effects  of  which  are  uniform  and  persistent. 


MATERIA   MEDIC  A   AND  THERAPEUTICS. 


221 


Effects  of  Iodide  of  Potassium  on  the  Assimilation  of  Nitrogenous 

Materials. 

Contradictory  opinions  have  been  expressed  as  to  the  action  of  iodide  of 
potassium  on  the  assimilation  and  metabolism  of  nitrogenous  matters.  Bock 
long  ago  (1869)  maintained  that  it  has  no  effect  of  this  kind,  but  subsequently 
Smirnow  demonstrated  that  it  does  promote  the  disassimilation  of  nitrogenous 
substances.  Recently  Samoilow  has  examined  the  question  anew  {Thesis  of 
St.  Petersburg,  1886)  by  a  series  of  laboratory  experiments,  dogs  being  used 
for  the  purpose,  and  he  concludes  that  small  doses  of  potassium  iodide  promote 
the  function  of  assimilation,  but  large  doses  act  in  the  opposite  manner, 
increasing  the  destructive  metamorphosis  of  the  nitrogenous  tissues  or 
materials.  No  doubt  the  waste  caused  by  this  agent  may  be  in  part  due  to 
its  action  on  the  mucous  membrane — to  the  swelling  and  desquamation  of  the 
epithelium  and  thrombosis  of  the  smaller  vessels  of  the  kidneys — hence 
Samoilow  holds  that  the  large  doses  of  iodide  of  potassium  recommended  by 
Keyes  are  dangerous. 

Effects  of  Alcohol  on  the  Digestive  Functions  in  the  Normal 
and  in  the  pathological  states. 

Dr.  A.  Gluzinski  has  examined  anew  this  much  debated  question  (Deut. 
Archiv f.  klin.  Medicin,  vol.  39,  1886).    His  conclusions  are  as  follows: 

Alcohol  disappears  rapidly  from  the  stomach.  Two  phases  of  the  effects 
on  digestion  are  to  be  noted :  in  the  first,  there  is  a  marked  diminution  in  the 
power  to  digest  albuminous  substances ;  the  second  phase  commences  after 
the  elimination  of  the  alcohol,  and  during  this  period  the  functional  activity 
of  the  stomach  is  such  that  digestion  is  completed  somewhat  earlier  than  in 
the  normal  state.  Alcohol  in  the  first  phase,  inhibits  the  activity  of  pepsin, 
but,  on  the  other  hand,  stimulates  the  gland  elements,  in  consequence  of  which 
during  the  second  phase  there  is  a  more  abundant  production  of  hydrochloric 
acid.  Dr.  Gluzinski  finds,  therefore,  that  a  small  amount  of  alcohol  exerts  a 
favorable  influence  on  the  digestion  of  healthy  persons. 

In  diseased  states,  after  the  absorption  of  a  certain  amount  of  alcohol,  the 
two  phases  of  digestion  are  much  less  pronounced,  and  hence  the  use  of 
alcoholic  drinks  is  not  to  be  recommended  in  such  morbid  conditions  of  the 
digestive  apparatus  as  dyspepsia. 

Pilocarpine  in  Catarrh  of  the  Tympanum. 

Kosengarten  has  recently  reported  the  good  effects  obtained  by  him  in 
catarrh  of  the  middle  ear,  by  subcutaneous  injections  of  pilocarpine  (Zeitschrift 
fur  Ohrenheilkunde,  1886,  vol.  xiv.,  quoted  in  Bull.  Gen.  de  Therap.,  April  15, 
1887). 

Politzer  was  the  first  to  call  attention  to  the  use  of  pilocarpine  in  recent 
affections  of  the  labyrinth,  and  these  observations  were  confirmed  subse- 
quently by  Moos  and  Wolff,  and  still  more  recently  by  Jacobson.  Kosen- 
garten conceived  the  notion  of  making  pilocarpine  injections  in  chronic 
troubles  of  the  middle  ear,  and  they  have  proved  to  be  highly  useful. 


222 


PROGRESS  OF    MEDICAL  SCIENCE. 


The  Hypodermatic  Injection  of  the  Insoluble  Salts  of  Mercury. 

The  treatment  of  syphilis  by  the  subcutaneous  injection  of  mercurial  salts 
yet  remains  an  undecided  question.  In  an  elaborate  historical  and  critical 
review  of  the  subject,  Dr.  Guelpa  seeks  to  establish  some  principles  for  more 
accurate  guidance  (Bui.  Gen.  de  TMrap.,  April  15,  1887). 

The  method  of  Scarenzio,  set  forth  in  his  great  work,  has  been  the  point  of 
departure  in  recent  times  in  the  therapeutical  applications  of  mercury  subcu- 
taneously.  Calomel  and  the  yellow  oxide  are  the  mercurial  salts  employed  by 
him,  and  his  conclusion  was  that  the  hypodermatic  method  is  superior  to 
friction  or  fumigation.  The  next  most  important  contributions  to  the  subject 
were  made  by  Smirnoff,  who  occupied  himself  with  determining  the  best 
site  for  the  injections,  as  well  as  the  general  principles  applicable.  Smirnoff 
advises  that  the  depression  in  the  hip  behind  the  great  trochanter  be  selected 
for  the  operation,  because  here  the  areolar  tissue  is  abundant,  loose,  and 
extensible.  Suitable  care  taken,  abscesses  do  not  form,  and  the  pain  and  dis- 
comfort are  reduced  to  the  minimum.  If  mercurialism  occur,  Smirnoff  holds 
that  it  is  due  to  impure  air,  and  the  mercurial  vapor  generated  in  an  apart- 
ment occupied  by  many  subjects  undergoing  the  mercurial  treatment.  It 
follows  that  careful  attention  to  ventilation  and  to  the  supply  of  pure  air 
becomes  necessary  to  success. 

Smirnoff  concludes  that  the  hypodermatic  method  is  required  where  prompt 
results  are  necessary;  that  it  is contraindicated when  mercurial  periostitis  has 
appeared ;  that  it  is  the  most  convenient  and  simple  of  the  methods  used ; 
that  it  is  applicable  to  all  ages  and  stages  of  the  disease ;  that  it  is  superior 
in  efficacy  to  the  treatment  by  inunction,  and  more  active  than  any  other 
mercurial  plan. 

Dr.  Guelpa,  in  concluding  his  memoir,  states  that  he  has  not  yet  attained 
to  a  final  conviction  on  the  subject,  but  he  expresses  the  opinion  based  on  an 
unprejudiced  examination  of  the  question,  that  the  hypodermatic  injection  of 
the  salts — especially,  perhaps,  of  the  insoluble  salts  of  mercury — must  be 
regarded  as  a  method  of  treating  syphilis  of  general  utility,  and  in  a  special 
case  incontestably  superior  to  all  other  plans. 

The  Preventive  Treatment  of  Syphilis. 

Prof.  Neumann  has  recently  published  the  results  of  his  clinical  work  in 
this  department  (abstracted  in  the  Bull.  Gen.  de  Th'erap.,  Feb.  15, 1887).  The 
so-called  "  preventive  treatment "  consists  in  excision  of  the  induration  and 
mercurial  inunctions.  Neumann  finds  that  extirpation  of  the  local  disease 
does  not  prevent  general  infection,  nor  does  the  mercurial  inunction  prove 
more  efficient  in  this  respect. 

The  expectant  treatment  is  rejected  by  him  because  of  the  great  length  of 
time  required,  because  such  subjects  continue  to  be  a  source  of  infection,  and 
because  the  ulterior  accidents  are  often  very  serious  in  character. 

Finger,  of  Vienna,  although  regarding  excision  as  possibly  successful, 
thinks  it  hazardous  on  the  whole.  He  is  opposed  to  the  preventive  method 
and  expectancy,  and  still  maintains  the  superiority  of  iodine  and  mercury 
in  the  treatment  of  all  the  manifestations  of  syphilis. 


MATEEIA   MEDICA   AND  THERAPEUTICS. 


223 


Treatment  of  Neuralgia  of  the  Fifth  Nerve. 

Prof.  Gussenbauer  [Prag.  med.  Wochenschrift,  No.  31,  1886,  quoted)  re- 
marks that  trigeminal  neuralgia  is  very  frequently  a  reflex  action  proceeding 
from  the  intestines  in  the  course  of  an  obstinate  constipation.  In  33  cases 
under  his  observation  there  were  but  3  requiring  surgical  interference,  and  in 
the  others  cures  were  obtained  by  methodical  treatment  of  the  constipation. 
In  most  of  the  cases  sensible  amelioration  occurred  in  about  fifteen  days  of  the 
treatment.  The  measures  employed  consisted  in  cold  enemata,  fomentations, 
and  cold  frictions  of  the  abdomen. 

Cocaine  in  Cardiac  Asthenia. 

Noorden  {Berliner  klin.  Wochenschrift,  No.  51,  1886)  has  had  good  results 
(veritab/ement  merveilleux)  in  pseudo-angina  pectoris  by  the  use  of  cocaine. 
He  offers  no  explanation  of  its  utility,  but  compares  its  action  in  these  cases 
to  that  obtained  by  Bescharner  in  bronchial  asthma. 

The  Formiates  and  their  Disposal  in  the  Organism. 

MM.  Grehaut  AND  Quinqtjad  publish  in  the  Archives  de  Physiologie,  April 
1,  1886,  an  elaborate  research  on  the  disposition  made  of  the  formiates  when 
introduced  into  the  body.  (Recherches  sur  les  Formiates  Introduits  dans  V  Or- 
ganisme.)  It  will  suffice  to  give  their  conclusions.  Although  not  a  matter  of 
immediate  practical  importance,  the  facts  may  serve  to  explain,  or  suggest  by 
analogy,  how  similar  substances  act  under  corresponding  conditions. 

MM.  Grehaut  and  Quinquad  conclude  that  when  formiate  of  soda  is  intro- 
duced into  the  digestive  canal  or  thrown  into  the  blood,  it  is  eliminated  by 
the  kidneys  without  undergoing  decomposition,  and  that  the  urine  contains 
no  more  than  the  usual  proportion  of  carbonates. 

Hot  Water  in  Acute  Prostatitis. 

Dr.  Cazeaux  ( These  de  Paris,  1886)  finds  that  hot  water  enemata  and  appli- 
cations to  the  perineum  are  very  effective  at  the  onset  of  prostatitis  and  before 
the  occurrence  of  suppuration.  He  advises  water  at  the  temperature  of  130° 
F.,  to  be  used  by  the  irrigator  three  times  a  day  to  the  perineum  and  in  the 
rectum. 

Massage  in  Sciatica. 

Prof.  Max  Muller  advocates  the  methodical  use  of  massage  in  sciatica. 
{Deut.  medinis.  Wochenschrift,  No.  24, 1886.)  Of  a  group  of  fifteen  patients  of 
varying  ages,  he  succeeded  admirably  in  all  by  this  treatment.  All  of  them 
were  severe  cases,  having  intense  pain  and  considerable  disorder  of  motility. 
Massage  was  applied  in  the  ordinary  way,  the  patient  lying  on  the  healthy 
side.  The  first  seances  were  painful,  but  the  irritability  of  the  nerves  rapidly 
subsided,  and  after  a  few  treatments  no  pain  was  caused  by  it  and  permanent 
relief  was  obtained. 


224 


PKOGKESS  OF   MEDICAL  SCIENCE. 


Sparteine. 

This  new  cardiac  remedy,  so  much  praised  by  Prof.  Germain  See,  has  been 
studied  by  Dr.  Stoessel,  of  Vienna,  and  his  observations  appear  in  the  Cen- 
tralblatt  fur  die  gesamrnte  Therapie  of  April,  1887. 

After  a  statement  of  the  opinions  given  by  See,  Dr.  Stoessel  narrates  his 
own  experiences.  In  respect  to  the  value  of  sparteine  in  the  condition  of 
arhythmia  of  the  heart,  due  to  weakness  of  the  heart- muscle,  he  does  not 
agree  with  Prof.  See,  who  maintains  that  it  is  superior  to  digitalis  here. 
Especially  does  Dr.  Stoessel  find  sparteine  inferior  to  digitalis  in  the  irregular 
rhythm  and  weakness  due  to  fatty  degeneration  of  the  heart. 

Another  fact,  showing  the  superiority  of  digitalis,  is  that  this  remedy  is  an 
efficient  diuretic,  while  sparteine  has  little  or  no  action  on  the  kidneys. 

Salol. 

In  the  Therapeut.  Monatsh.,  p.  47, 1887,  Bielchowski  publishes  the  results  of 
his  experience  with  salol  in  acute  rheumatism.  In  the  quantity  of  5  grammes 
a  day  (75  grains)  it  acts  promptly  in  arresting  the  disease,  and,  when  a  relapse 
occurs,  a  single  dose  will  usually  prove  immediately  successful. 

Eosenberg  has  also  employed  it  with  complete  success.  Its  advantages  are. 
that  it  does  not  disturb  the  digestive  organs,  and  is  not  difficult  to  administer ; 
but  the  chief  point  is,  the  curative  power,  which  is  so  much  greater  than  the 
salicylates  have,  but  there  is  no  evidence  to  show  that  it  succeeds  better  than 
other  agents  in  preventing  the  cardiac  complications. 

We  submit  some  further  observations  on  salol,  that  our  readers  may  have 
the  data  for  forming  correct  conclusions.  A  full  abstract  from  a  paper  by 
Dr.  Fr.  Eduard  Georgi,  is  published  in  the  Centralblatt  fur  die  Therapie  for 
April,  1887,  from  which  we  obtain  the  facts  here  given. 

As  regards  the  topical  use  of  salol,  Dr.  Georgi  did  not  find  it  superior  to  the 
remedies  now  employed  for  the  relief  of  nasal  and  pharyngeal  diseases.  By 
the  stomach  it  may  be  given  in  doses  of  10  to  30  grains  without  inconvenience. 
In  a  case  of  febrile  icterus  it  had  a  rapid  effect,  both  in  reducing  the  fever 
and  clearing  up  the  jaundice.  It  proved  to  be  effective  in  lessening  the  tem- 
perature of  the  phthisical  also. 

In  pyonephritis,  cystitis,  etc.,  it  was  found  to  be  very  active  in  checking 
suppuration;  and  preventing  and  removing  the  products  of  decomposition  of 
the  urine. 

In  acute  rheumatism  Georgi  ascertained  it  to  be  exceedingly  valuable,  one 
or  two  doses  often  relieving  the  pain  entirely,  and  in  all  cases  relief  was 
obtained  in  two  or  three  days.  Two  grammes  (30  grains),  in  the  twenty-four 
hours,  were  found  to  be  sufficient,  and  it  was  rarely  necessary  to  administer 
more  than  ten  to  twelve  grammes  (150  to  180  grains),  in  all,  to  effect  the 
removal  of  the  rheumatic  pains.  When  this  was  accomplished,  the  dose  was 
reduced  to  15  grains  a  day  until  complete  recovery.  Eelapses  were  not 
frequent.  The  largest  dose  given  caused  no  unpleasant  sensations,  and  only 
in  three  out  of  twenty  cases  was  buzzing  in  the  ears  brought  on.  Weakness 
of  the  heart,  small  pulse,  or  indications  of  collapse,  never  occurred.  As  an 
antipyretic  in  febrile  disease  salol  proved  to  be  certain  in  its  action  and 


MEDICINE. 


225 


powerful,  but  massive  doses  are  necessary — from  30  to  60  grains.  Unlike  the 
other  antipyretics  of  this  group,  salol  induced  but  moderate  perspiration. 

Iodol  and  Iodoform. 

Schnirer  makes  (Semaine  Medicate,  1886,  p  406,  quoted  by  Bull.  G'en.  de 
Therap.,  February  15,  1887)  some  observations  on  the  comparative  utility  of 
iodoform  and  iodol. 

As  the  odor  of  iodoform  is  so  strong,  diffusive,  and  penetrating,  iodol  is  a 
happy  substitute,  since  it  has  but  little  taste  or  odor.  It  is  a  brown  powder, 
which  may  be  used  topically,  or  taken  internally,  in  the  quantity  of  25  to  50 
centigrammes  (4  to  8  grains).  Experience  has  confirmed  the  original  state- 
ments as  to  its  utility.  It  is  equally  effective  with  iodoform,  and  can  be  sub- 
stituted for  the  latter  in  the  whole  range  of  the  topical  uses,  and  probably, 
also,  for  internal  administration. 

Chlorhydrate  of  Pereirine. 

In  a  recent  communication  (Bull.  Gen.  de  TMrap.,  April  15,  1887)  Dr. 
Ferreira,  of  Brazil,  calls  attention  to  the  power  of  chlorhydrate  of  pereirine 
in  the  cure  of  malarial  infection.  This  alkaloid  is  obtained  from  a  member  of 
the  Apocynacese,  which  grows  spontaneously  and  in  great  abundance  in 
Brazil.  The  dose  prescribed  by  Dr.  Ferreira  is  two  grammes  (about  3ss),  in 
two  parts,  at  a  half-hour  interval.  He  finds  it  an  efficient  antiperiodic,  less 
irritating  to  the  stomach  than  quinine,  and  sometimes  successful  when  quinine 
has  entirely  failed.    It  appears  to  be  more  useful  in  the  acute  cases. 


(  MEDICINE. 


UNDER  THE  CHARGE  OF 

WILLIAM  OSLEE,  M.D.,  F.R.C.P.  Lond., 

professor  of  clinical  medicine  in  the  university  of  pennsylvania. 
Assisted  by 

J.  P.  Crozer  Griffith,  M.D.,  Walter  Mendelson,  M.D., 

ASSISTANT  TO  THE  PROFESSOR  OF  CLINICAL  MEDICINE  INSTRUCTOR  IN  THE  LABORATORY  OF  THE  COLLEGE 

IN  THE  UNIVERSITY  OF  PENNSYLVANIA.  OF  PHYSICIANS  AND  SURGEONS,  NEW  YORK. 


On  some  Cases  of  Infectious  Cerebro-spinal  Meningitis,  with 
Remarks  on  the  Diagnosis  of  the  Disease. 

Senator  (Charite  Annalen,  xi.  248,  1886)  reports  eight  cases  of  this  affec- 
tion, and  emphasizes  the  difficulty  attending  its  diagnosis.  The  disease  can 
be  most  easily  confounded  with  typhoid  fever,  tetanus,  and  with  other  forms 
of  meningitis  cerebro-spinalis.  But  even  in  cases  of  cerebral  hemorrhage 
into  the  meninges  or  ventricles,  where  decided  stiffness  of  the  neck  is  com- 

NO.  CLXXXV1I.— JULY,  1887.  15 


226 


PROGKESS   OF   MEDICAL  SCIENCE. 


bined  with  spasm  and  contractures  of  the  extremities,  a  confusion  with  cere- 
bro-spinal  meningitis  may  arise,  especially  as  absence  of  the  tendon  reflexes 
is  observed  in  severe  cases  of  the  latter  affection. 

Acute  rheumatic  arthritis  of  the  articulations  of  the  vertebral  column,  nar- 
cotic poisons  and  those  producing  spasm,  urasmia,  diabetic  coma  and  the 
nearly  allied  coma  of  other  dyscrasic  conditions,  are  also  to  be  borne  in 
mind  in  forming  a  diagnosis.  The  previous  history  of  the  disease  in  each 
case  is  of  the  greatest  importance,  since  in  other  disorders  the  symptoms 
usually  do  not  occur  in  the  same  order  as  in  cerebro-spinal  meningitis.  At 
the  height  of  the  disease  there  are  to  be  observed  a  stiffness  of  the  neck,  various 
eruptions  of  the  skin— especially  herpes,  fever,  and  sweats  which  are  not 
critical.  The  swellings  of  the  joints,  which  develop  later  in  the  disease,  are 
of  diagnostic  import.  In  one  case  it  was  observed  that  the  diazo  reaction 
was  absent.  This  feature,  if  confirmed,  would  be  of  importance  as  distin- 
guishing the  disease  from  typhoid. 

Mountain  Fever. 

In  a  "Report  on  the  Topography,  Botany,  Climatology,  and  Diseases  of 
Surprise  and  Goose  Lake  Valleys,  California,"  by  Kober,  we  find  a  short 
notice  of  mountain  fever.  He  says  that  it  differs  essentially  from  the  clinical 
pictures  of  enteric  and  remittent  fevers,  and  represents,  he  believes,  a  union 
of  the  typhoid  and  malarial  poisons.  The  disease  is  ushered  in  by  a  chill  or 
chilly  sensation,  repeated  during  two  or  three  days.  There  is  some  aching  of 
the  head  and  of  nearly  every  part  of  the  body.  The  tongue  is  covered  with 
a  thick  yellowish  or  bluish  fur,  but  with  the  borders  and  tip  clean  and  red. 
Often  there  is  slight  pharyngeal  and  nasal  catarrh.  The  temperature  reaches 
101°-104°  F.,  and  in  the  first  stage  of  the  disease  especially  exhibits  marked 
exacerbations  and  remissions,  suggestive  of  quotidian  and  remittent  fevers. 
The  pulse  is  90-110  and  full;  epistaxis  and  abdominal  symptoms  are  rare  in 
the  early  stages;  there  is  no  eruption;  herpes  is  common;  sweating  more 
common  than  in  typhoid.  The  fever  continues  four  or  five  weeks,  and  in  the 
graver  forms  abdominal  and  adynamic  symptoms  develop.  Early  treatment 
usually  cuts  the  disease  short;  but  if  neglected,  it  runs  ^nto  the  typhoid  stage 
and  quinine  has  no  curative  influence.  He  has  often  seen  the  disease  attack 
men  who  have  lived  in  places  where  it  seems  impossible  that  the  typhoid 
germ  could  have  existed.  He  thinks  it  likely  that  this  was  obtained  from  the 
pollution  of  some  of  the  mountain  streams  by  beaver  dams  and  large  game. 
The  author  agrees  with  Hoff  (Amer.  Journ.  Med.  Sci.,  for  January,  1880), 
who,  following  Woodward,  calls  the  affection  typho-malarial  fever,  and 
believes  that  it  is  a  hybrid  disease — i.  e.,  typhoid,  modified  by  intermittent. 
He  says  that  it  begins  as  an  intermittent,  and  that  this  stage  is  followed  in 
two  weeks  by  the  typhoid  stage,  which  lasts  about  four  weeks,  and  exhibits 
the  typical  typhoid  symptoms.  A  postscript  by  Woodward  confirms  him  in 
the  statement  that  necropsies  almost  always  reveal  the  lesions  of  typhoid. 

This  would  seem  to  be  conclusive,  but  it  is  but  right  to  say  that  opinions 
are  somewhat  divided.  Smart  (Amer.  Jotjrn.  Med.  Sci.,  34,  1878)  claims 
that  mountain  fever  is  only  a  malarial  remittent  with  adynamic  tendencies. 
Hirsch  {Handb.  of  Geog.  and  Hist.  Path.,  Eng.  transl.,  1883)  refers  to  it  as  a 


MEDICINE. 


227 


variety  of  malaria.  There  is  also  some  unfortunate  confusion  in  the  name 
employed.  Squire,  in  the  last  number  of  this  journal,  describes  typho- 
malarial  fever  as  malarial  fever  which  has  assumed  the  adynamic  type  present 
in  typhoid  fever,  and  applies  the  name  "malarial  enteric"  to  those  cases  in 
which  there  is  a  union  of  both  diseases,  as  seems  to  be  the  case  in  mountain  fever. 

The  Microorganisms  in  the  Varicella  Vesicle. 

Guttmann  (  Virchow's  Archiv,  B.  cvii.  H.  2,  259)  has  investigated  the  con- 
tents of  the  vesicles  in  three  cases  of  varicella,  with  regard  to  the  presence  of 
bacteria.  In  cultures  made  upon  agar-agar,  he  discovered  three  varieties  of 
cocci :  1st,  the  Staphylococcus  aureus ;  2d,  one  which  he  names  Staphylococcus 
viridis  flavescens,  which  is  characterized  upon  the  culture  medium  by  a  color 
at  first  resembling  that  of  an  unripe  lemon,  and  later  becoming  more  yellow. 
It  is  never  white;  3d,  a  coccus  exhibiting  on  agar-agar  culture  a  white  color. 

Inoculations  of  these  cultures  upon  animals  were  without  result,  except  in 
the  case  of  the  Staph,  aureus,  which  proved  fatal  in  one  instance.  Guttmann 
believes  that  cocci  of  various  other  species  may  occur  in  the  varicella  vesicles, 
and  refers  to  a  species  previously  reported  by  Bareggi. 

Peripheral  Neuritis. 

In  discussing  this  subject  in  the  Brit.  Med.  Journal,  1887,  p.  6,  Eoss  says  that 
the  symmetrical  manner  in  which  the  disease  usually  attacks  the  body  shows 
that  at  least  in  the  majority  of  cases  it  is  produced  by  some  poison  in  the 
blood.  Thus  salts  of  lead,  arsenic,  and  probably  of  copper  and  other  metals 
are  capable  of  giving  rise  to  it.  In  a  second  group  of  cases  the  disease  is  caused 
by  alcoholic  excess,  the  fumes  of  bisulphide  and  oxide  of  carbon,  and  proba- 
bly by  the  abuse  of  chloral  and  chloroform.  It  has  also  been  observed  in 
advanced  diabetes.  A  third  variety  arises  from  animal  poison.  Diphtheritic 
paralysis  is  the  best  known  instance  of  this.  It  is  also  to  be  observed  in 
syphilis,  smallpox,  scarlet  fever,  measles,  typhoid,  typhus,  intermittent  fever, 
dengue,  tuberculosis,  leprosy,  and  beri-beri.  It  is  probable  that  it  may  be 
caused  by  rheumatism,  and  that  the  wasting  of  the  extensors  seen  in  chronic 
rheumatoid  arthritis  is  due  to  a  neuritis  of  the  neighboring  nerves.  There  is 
also  an  idiopathic  multiple  neuritis. 

The  symptoms  consist  in  more  or  less  widely  distributed  atrophic  paralysis. 
Ross  has  never  been  able  to  assure  himself  that  active  spasm  preceded  the 
paralysis  in  any  case.  The  condition  of  the  cutaneous  reflexes  varies.  With 
a  very  few  exceptions,  the  patellar  reflex  has  been  wanting  in  all  recently 
reported  cases  of  alcoholic,  diphtheritic,  and  other  forms  of  neuritis  of  the 
lower  extremities.  The  knee-jerk  is  sometimes  absent  in  lead  poisoning,  even 
when  the  muscles  of  the  lower  extremities  are  not  appreciably  involved.  Yet 
the  failure  of  the  patellar  reflex  is  a  valuable  but  not  an  absolute  sign  of  neu- 
ritis. The  electrical  test  affords  conclusive  evidence  in  the  majority  of  cases. 
The  faradic  excitability  of  the  affected  nerves  and  muscles  is  lessened  or  abol- 
ished, and  the  reaction  of  degeneration  is  detected  with  the  galvanic  current. 
The  paralysis  affects  especially  the  extensors,  as  is  well  seen  in  the  "wrist- 
drop" of  lead  palsy.  That  following  alcohol,  bisulphide  of  carbon,  the  animal 
poisons,  and  even  arsenic,  usually  attacks  the  extensors  of  the  lower  extremi- 


228 


PROGRESS  OF   MEDICAL  SCIENCE. 


ties  first.  Paralysis  of  the  extensors  of  the  forearm  soon  follows  in  alcoholic 
neuritis,  then  the  thighs  and  upper  arm,  then  the  flexors  of  the  leg  and  fore- 
arm, and  finally  even  the  muscles  of  the  trunk  may  become  involved. 

In  diphtheritic  paralysis  the  soft  palate  is  the  first  to  be  affected  ;  then  the 
muscles  of  the  eye,  and  after  some  time  the  lower  extremities.  The  arms  are 
seldom  involved. 

The  paralysis  of  the  extensors  in  neuritis  produces  a  temporary  or  perma- 
nent flexion  of  the  limb,  simulating  a  spasm  of  the  flexors. 

The  sensory  disturbances  accompanying  the  paralysis  resemble  considerably 
those  of  locomotor  ataxia. 

The  disease  may  most  easily  be  confounded  with  chronic  poliomyelitis, 
Landry's  paralysis,  and  locomotor  ataxia.  From  the  first  it  is  distinguished 
by  the  presence  of  well-marked  sensory  phenomena,  and  by  the  order  in 
which  the  muscles  are  attacked.  From  the  second  it  differs  in  exhibiting  the 
reaction  of  degeneration  with  marked  sensory  disturbances  and  wasting  of  the 
muscles.  From  the  third  it  differs  in  many  respects,  but  the  character  of  the 
gait  is  sufficient  to  distinguish  it.  We  observe,  namely,  in  neuritis  a  peculiar 
elevation  of  the  knee  in  walking,  with  a  drooping  of  the  toes,  and  an  unusual 
exposure  of  the  sole  of  the  foot  to  one  standing  behind  the  patient.  Such  a 
case  is  unable  to  elevate  the  toes  if  sitting  on  a  chair  with  the  soles  flat  on 
the  floor. 

As  regards  the  pathological  anatomy  of  the  disease,  the  author  shows  that 
opinions  are  now  generally  agreed  that  the  lesion  is  seated  in  the  nerves 
themselves  and  not  in  the  cord. 

On  Pseudo-Tabes  from  Arsenical  Poisoning. 

Dana  (Brain,  xxxvi.  456, 1887)  reports  two  cases  and  makes  a  careful  study 
of  the  literature  of  arsenical  paralysis,  appending  over  100  references.  He 
concludes  that  there  are  two  forms  of  this,  just  as  there  are  of  diphtheritic  and 
alcoholic  paralysis. 

1.  The  ordinary  arsenical  paralysis,  in  which  the  motor  affection  and  the 
atrophy  are  more  marked  than  the  sensory  derangement. 

2.  Arsenical  pseudo-tabes,  in  which  there  is  no  pronounced  motor  paralysis, 
but  decided  sensory  disturbance,  especially  ataxia. 

It  is  entirely  improbable  that  either  of  these  forms  is  due,  as  a  rule,  to  a  dif- 
fuse myelitis,  but  rather  to  a  multiple  neuritis ;  just  as  is  the  case  in  paralysis 
from  lead,  alcohol,  diphtheria,  and  probably  from  other  infections  and  poisons. 

On  the  Early  Becognition  of  General  Paralysis  of  the  Insane; 
and  the  kelation  between  this  disease,  tabes  dorsalis,  and 
Disseminated  Sclerosis. 

J.  Syer  Bristowe,  in  an  address  reported  in  the  British  Medical  Journal 
for  1887,  p.  1,  states  that,  although  typical  cases  of  general  paralysis  are  easily 
diagnosticated,  yet,  in  many  instances,  especially  in  the  early  stage,  at  a 
time  when  a  diagnosis  is  so  much  to  be  desired,  the  recognition  of  the  nature 
of  the  disorder  is  difficult,  if  not  impossible.  " 

He  gives  a  synopsis  of  the  symptoms,  mentioning  the  fact  that  epileptiform 
attacks  and  other  mental  derangements  may  occur  in  all  these  disorders.  In 


MEDICINE. 


229 


general  paralysis  of  the  insane  the  paralytic  symptoms  are  most  pronounced 
in  connection  with  the  organs  of  speech.  The  usual  duration  of  the  disease 
is  said  to  be  two  or  three  years,  but  it  is  probable  that  early  indications,  con- 
sisting of  slight  degrees  of  some  of  the  characteristic  phenomena,  may  be 
detected  by  the  careful  observer  years  before  the  first  outspoken  symptoms 
become  noticeable. 

Bristowe  reports  a  series  of  interesting  cases  of  general  paralysis,  illus- 
trating the  occasional  difficulty  of  diagnosis.  In  one  patient,  for  example, 
with  fairly  characteristic  signs  of  general  paralysis  were  associated  symptoms 
both  of  tabes  and  of  disseminated  sclerosis.  In  this  and  in  several  other  cases 
delusions  never  occurred.  He  then  describes  three  cases,  probably  of  loco- 
motor ataxia,  in  which,  however,  there  was  so  much  mental  disturbance  that 
the  diagnosis  might  be  open  to  question. 

Sudden  Death  in  Pleurisy. 

Weill  {Rev.  de  Med.,  1887,  33-64)  reports  a  case  of  sudden  death  in  pleu- 
risy, and  gives  the  notes  of  twenty-six  others  gathered  from  the  literature,  and 
which  seem  to  him  to  fill  the  conditions  of  an  exitus  truly  sudden.  He 
excludes  all  cases  of  death  from  increasing  asphyxia  lasting  some  hours ;  and 
omits,  too,  all  those  in  which  thoracentesis  had  been  performed,  and  death 
followed  immediately  or  more  remotely.    His  conclusions  are  as  follows  : 

1.  Sudden  death  in  pleurisy  appears  to  be  associated  with  certain  lesions, 
of  which  the  principal  are — thrombosis  or  embolism  of  the  heart  and  of  the 
pulmonary  artery ;  sudden  oedema  of  the  lung  on  the  side  non-affected  with 
pleurisy;  alterations  of  the  myocardium.  These  last  often  escape  notice  at  the 
autopsy,  since  they  demand  the  aid  of  the  microscope  for  their  detection.  In 
some  cases  no  cause  at  all  can  be  found. 

2.  Cases  of  death  attributed  to  simple  functional  trouble,  such  as  severe 
syncope;  or  to  mechanical  interference,  as  displacement  of  the  heart,  torsion 
of  the  vessels,  the  bending  of  the  ascending  vena  cava  at  a  right  angle ;  or  to 
hypothetical  lesions,  as  capillary  embolism  of  the  brain ;  ought  to  be  admitted 
with  great  reserve. 

3.  Sudden  death  may  occur  in  the  most  diverse  varieties  of  pleurisy.  The 
affection  may  be  on  either  side  (oftener  the  right)  ;  acute  or  chronic ;  with 
the  effusion  increasing,  stationary,  or  decreasing.   The  liquid  is  usually  serous. 

4.  Pleurisy  ending  in  sudden  death  may  or  may  not  be  accompanied  by 
peculiar  symptoms.  There  may  be  increase  of  dyspncea,  premonitory  syn- 
cope, and  irregular  pulse.  Very  often  death  occurs  when  the  case  appears  to 
be  making  most  satisfactory  progress.  It  is  usually  produced  by  some  sudden 
effort. 

5.  Treatment  is,  of  course,  useless,  when  we  have  to  do,  for  example,  with 
lesions  of  the  myocardium.  The  prophylactic  treatment  in  other  cases  is 
thoracentesis.  It  is  indicated  either  in  the  acute  or  chronic  stage  if  threaten- 
ing symptoms  be  present,  or  if  there  be  increase  of  the  intra-pleural  pressure. 

On  Cases  of  Valvular  Disease  of  the  Heart,  Existing  for  over 
Five  Years  without  Serious  Symptoms. 

Sir  Andrew  Clark  {Brit.  Med.  Journ.,  260,  325,  370,  1887)  extracts  from 
the  clinical  histories  of  his  office  patients  since  1873,  684  cases  in  which  there 


230 


PKOGKESS  OF   MEDICAL  SCIENCE. 


existed  well-marked  chronic  valvular  disease  of  the  heart,  not  indicated  by 
any  symptom,  and  not  interfering  with  the  patient's  health.  A  series  of 
elaborate  tables  accompanies  the  text.  Concerning  the  diseases  for  which  the 
patients  were  receiving  treatment,  it  appears  that  nearly  one-half  were  affec- 
tions of  the  digestive  system,  and  about  one-fifth  diseases  of  the  nervous  system. 

The  author  relates,  by  way  of  illustration,  a  number  of  very  interesting  and 
instructive  cases,  not  included  in  the  tables,  showing  that  the  evidences  of 
the  gravest  cardiac  lesions  could  coexist  with  excellent  health. 

Many  of  the  patients  had  been  told  by  physicians  previously  in  attendance 
that  they  could  live  but  a  short  time.  To  others  the  strictest  rules  of  diet  and 
of  exercise  had  been  given,  with  the  result  that  both  health  and  happiness 
suffered  greatly.  For  all  of  these  cases,  Clark  recommended  a  return  to  the 
ordinary  hygienic  regime  necessary  for  the  physiological  conditions  of  life. 
He  warns  us,  however,  that  this  is  only  suitable  to  chronic  and  stationary 
cases.  When  the  heart  is  irritable,  irregular,  or  frequent;  when  the  mur- 
murs vary  in  character  and  intensity,  or  when  there  is  any  febrile  action,  pa- 
tients must  be  kept  at  rest,  and  the  lightest  diet  administered.  Any  other 
course  is  most  unsafe. 

The  author  next  reports  several  cases  showing  that  well-established  cardiac 
lesions  having  lasted  several  years,  and  due  to  inflammation  of  the  valves, 
may  in  later  years  entirely  disappear.  This  may  be  observed  in  the  case  of 
the  mitral  bruit  often  heard  in  chorea,  and  dependent  on  organic  changes. 
These  murmurs  of  chorea,  in  fact,  usually  disappear  eight  or  nine  years  after 
the  attack.  The  same  disappearance  of  all  evidence  of  disease  can  often  be 
observed  years  after  a  rheumatic  endocarditis  had  produced  a  loud  systolic 
murmur.  Although  such  recoveries  are  often  seen  in  the  young,  yet  they 
sometimes  take  place  in  the  old,  and  the  author  quotes  cases  in  substantiation 
of  this  fact.  Even  well-marked  valvular  defects  of  a  degenerative  nature 
may  in  rare  cases  disappear.  There  must  be  differential  between  the  histories, 
habits,  surroundings,  occupations,  etc.,  of  those  who  suffer  and  die  of  heart 
disease,  and  of  those  who  are  not  in  the  least  incommoded  by  its  presence. 

According  to  Clark,  the  factors  necessary  in  mitral  disease  for  the  exemp- 
tion from  unpleasant  cardiac  symptoms,  and  for  the  continuance  in  the  duties 
and  enjoyments  of  life,  are  as  follows :  1,  good  general  health ;  2,  just  habits  of 
living ;  3,  no  exceptional  liability  to  rheumatic  or  catarrhal  affections ;  4,  ori- 
gin of  the  valvular  lesion  independently  of  degeneration;  5,  existence  of  the 
valvular  lesion  without  change  for  over  three  years;  6,  sound  ventricles  with 
moderate  frequency  and  general  regularity  of  action  ;  7,  sound  arteries,  with  a 
normal  amount  of  blood  and  tension  in  the  smaller  vessels;  8,  free  course  of 
blood  through  the  cervical  veins ;  9,  freedom  from  pulmonary,  hepatic,  and 
renal  congestion.  The  prognosis  in  aortic  disease  is  not  so  favorable  even 
under  the  same  conditions. 

On  the  General  Pathology  of  Heart  Diseases. 

We  make  the  following  extracts  from  the  posthumous  paper  of  Schott  on 
this  subject  {Zeitsch.  f.  klin  Med.,  B.  xii.  H.  4,  295) : 

Insufficiency  of  the  heart  muscle.  This  may  be  absolute  or  relative.  In  abso- 
lute insufficiency  there  is  no  obstruction  to  the  circulation,  but  an  absolute 


MEDICINE. 


231 


diminution  of  muscle  power.  The  heart  muscle,  like  other  muscles,  is  sub- 
ject to  atrophic  changes  from  improper  nutrition,  lack  of  bodily  and  mental 
exercise,  accumulation  of  fat,  etc.  "Fatty  heart"  can  be  cured  without  any 
loss  of  weight;  but  the  usual  treatment  of  obesity  may  act  very  injuriously 
on  the  heart  by  affecting  the  general  nutrition.  In  very  fat  persons  of  great 
bodily  and  mental  energy  the  heart  retains  its  strength,  as  do  other  muscles. 
In  purely  relative  insumcienc}r  there  is  some  obstruction  to  the  circulation, 
but  the  heart  muscle  preserves  its  normal  power.  In  reality,  however,  rela- 
tive insufficiency  is  almost  always  combined  with  some  loss  of  muscular 
strength.  Complete  compensation  may  exist  or  become  developed. 
Dilatation.    Of  this  he  makes  two  classes : 

1.  Dilatation  which  necessarily  accompanies  certain  valvular  lesions  This, 
with  muscular  hypertrophy,  forms  an  essential  factor  of  the  compensation.  It 
may  be  called  "compensatory  dilatation."  It  is  exemplified  in  the  left  ven- 
tricle in  aortic  and  mitral  disease. 

2.  The  second  form  is  characteristic  of  diseases  of  the  muscle  substance 
and  of  insufficient  compensation.  It  is  only  the  expression  of  an  engorge- 
ment of  the  heart  with  blood,  and  might  be  named  "dilatation  of  engorge- 
ment." It  is  very  well  represented  by  dilatation  of  the  right  heart  following 
valvular  disease  of  the  left  side,  and  by  that  of  the  left  heart  due  to  renal 
disease.  It  is  produced  by  an  imperfect  emptying  of  the  ventricle  during 
systole.  Dilatations  of  this  form  disappear  with  the  development  of  complete 
compensation.  After  a  few  minutes  of  proper  gymnastic  exercise,  the  per- 
cussion boundaries  of  the  heart  sometimes  become  lessened.  On  the  other 
hand,  various  causes  may  visibly  increase  the  dilatation,  as  shown  by  the 
cardiac  dulness. 

The  cardiac  murmurs.  In  numbers  of  cases  murmurs  which  were  judged 
to  be  organic  disappeared  after  a  time.  This  is  a  strong  proof  that  there  had 
been  no  anatomical  lesiou.  The  sudden  appearance  and  disappearance  of 
murmurs  may  very  often  be  observed.  A  murmur  may  sometimes  be  made 
to  vanish  in  a  few  minutes  through  the  diminution  of  dilatation  produced  by 
light  gymnastics.  The  transition  from  mitral  murmur  to  a  divided  (gespaltene) 
tone,  which  is  often  detected,  is  a  probable  proof  of  an  abnormal  action  of  the 
papillary  muscle  and  of  the  absence  of  a  valvular  lesion.  The  author  admits, 
however,  that  a  recent  mitral  insufficiency  due  to  endocarditis  may,  in  rare 
cases,  really  heal.  There  exists  an  aortic  insufficiency  from  dilatation  of  the 
aorta  through  high  arterial  tension.  This  murmur  may  disappear ;  but  the 
author  doubts  whether  true  aortic  insufficiency  ever  is  curable. 

Peripheral  passive  congestion  and  hydrops.  Diminution  of  the  amount  of 
urine  is  a  necessary  result  of  heart  disease,  but  need  not  be  attended  by  dropsy. 
But  when,  through  thirst,  an  increased  quantity  of  fluid  is  brought  into  the 
system,  hydrops  appears.  This  increased  thirst  is  induced  by  the  retention 
in  the  blood  of  the  solid  elements  of  the  urine.  In  other  instances  growing- 
weakness  of  the  right  ventricle  produces  a  like  result.  In  all  cases  the  prog- 
ress of  the  circulatory  disturbance  is  aided  by  the  passive  hyperemia  of  the 
kidneys ;  and  although  the  heart  may  grow  stronger  through  treatment,  the 
kidneys  remain  affected,  and  we  find  a  clinical  picture  closely  resembling  that 
of  contracted  kidney.  Great  and  painful  increase  in  the  size  of  the  liver  due 
to  engorgement  occurs  early,  even  before  any  oedema  or  albuminuria  appears; 


232 


PROGRESS   OF   MEDICAL  SCIENCE. 


but  may  be  strikingly  diminished  by  suitable  gymnastics.  The  congestion  of 
the  lungs,  liver,  stomach,  etc.,  is  often  much  relieved  by  the  development  of 
oedema  of  the  subcutaneous  connective  tissue.  When  the  condition  of  en- 
gorgement becomes  extreme,  an  element  of  inflammation  is  added.  The 
pulmonary  hyperemia  becomes  splenization,  the  hydrothorax  exhibits  friction 
sounds,  and  erysipelas  is  very  apt  to  appear. 

New  Investigations  on  the  Gallop  Rhythm. 

Ctjffer  and  Barbillion  publish  a  long  article  in  the  February  and  March 
numbers  of  the  Archives  Q'en'erales  de  Medecine,  1887,  in  which  they  describe 
the  gallop  rhythm  as  made  up  of  two  normal  heart  sounds,  to  which  is  added 
a  third  abnormal  one  separated  from  them  by  an  interval  longer  than  in  the 
case  of  a  simple  reduplicated  beat.    They  draw  the  following  conclusions  : 

1.  A  more  complete  classification  of  the  varieties  of  gallop  rhythm  can  be 
made  than  that  at  present  adopted. 

2.  Gallop  rhythms  are  diastolic  or  mesosystolic,  according  to  the  place  which 
the  abnormal  bruit  occupies  in  the  cardiac  cycle.  In  the  first  it  immediately 
precedes,  and  in  the  second  it  immediately  follows  the  cardiac  impulse. 

3.  The  diastolic  gallop  may  itself  be  subdivided,  according  to  whether  it  is 
produced  in  the  left  or  the  right  heart. 

4.  The  left  diastolic  gallop  may  be  permanent  or  transitory  ;  having  in  each 
case  a  different  pathogenesis. 

5.  The  permanent  left  diastolic  gallop  is  due  to  a  hypertrophy  of  the  left 
ventricle,  itself  a  result  of  a  reflex  influence  from  disease  of  the  kidney ;  or  of 
a  permanent  increase  of  arterial  tension  caused  by  a  chronic  nephritis  or 
general  arterio-sclerosis. 

6.  The  additional  beat  is  presystolic.  It  is  a  bruit  of  diastolic  tension, 
caused  by  the  blood  forcibly  entering,  during  systole,  a  rigid  and  unyielding 
left  ventricle. 

7.  If  the  superadded  sound  is  heard  very  close  before  the  first  normal  sound, 
it  is  an  evidence  of  concentric  hypertrophy  without  dilatation.  When  it  is 
separated  by  a  longer  interval,  and  tends  to  approach  the  second  sound  of  the 
preceding  cycle,  it  is  an  indication  of  dilatation,  and  the  prognosis  is  more 
unfavorable. 

8.  Transitory  left  diastolic  gallop  is  observed  in  acute  affections  of  the 
kidneys,  or  in  exacerbations  of  chronic  affections.  There  is  a  spasmodic 
state  of  the  cardio-arterial  system,  with  a  resulting  transitory  high  tension. 

9.  Right  diastolic  gallop  is  produced  by  a  reflex  action  from  some  gastric, 
hepatic,  or  intestinal  disorder,  exciting  a  spasm  of  the  arterioles  of  the  lungs, 
with  an  increased  tension  in  the  right  heart.  This  increased  tension  causes 
the  abnormal  bruit  in  a  manner  analogous  to  its  production  in  the  left  heart. 

10.  The  mesosystolic  gallop  rhythm  is  characterized  by  an  additional  sound 
occupying  the  shorter  silence. 

11.  There  exist  all  grades  of  this,  between  the  simple  prolongation  of  the 
first  sound  and  the  most  clearly  marked  reduplication. 

12.  It  is  the  index  of  insufficiency  of  the  cardiac  systole  which  is  sometimes 
slow  and  languid,  sometimes  acting  twice  to  enable  the  ventricle  to  expel  the 
blood  which  it  contains. 


MEDICINE. 


233 


13.  The  writers  have  met  this  variety  of  gallop  rhythm  in  several  cases  of 
typhoid  fever,  in  one  of  tuberculosis,  and  in  one  of  mechanical  interference  with 
the  heart.    It  might  be  met  with  wherever  the  heart  is  failing  from  any  cause. 

Finally,  they  reiterate  that  the  diastolic  gallop  is  a  bruit  of  cardiac  strength 
with  high  arterial  tension,  and  the  mesosystolic  an  asthenic  bruit  with  feeble 
tension. 

Morphine  in  Diabetes. 

T.  Mitchell  Bruce  {Practitioner,  1887,  20)  was  induced  by  his  success 
with  morphia  in  the  treatment  of  a  series  of  cases  of  diabetes,  to  study  from 
a  therapeutic  standpoint  some  of  the  still  unsolved  questions  concerning  the 
pathology  of  the  disease.  By  administering  morphia  per  orem  to  a  selected 
case,  and  thus  reaching  the  liver  through  the  portal  circulation,  the  glycosuria 
was  made  to  disappear.  When  as  large  doses  of  the  drug  as  the  patient 
could  bear  were  given  hypodermatically,  almost  no  effect  on  the  elimination 
of  sugar  was  obtained.    The  author  concludes  that,  in  the  case  in  question, 

1st.  The  glycosuria  was  due  to  an  increased  ingress  of  sugar  into  the  blood ; 
not  to  a  diminished  destruction  of  it  in  the  system,  else  the  hypodermatic  use 
of  morphia  would  not  have  been  without  effect. 

2d.  The  increased  ingress  of  sugar  was  not  caused  by  a  simple  transporta- 
tion of  sugar  from  the  intestine  or  portal  vein  to  the  general  circulation,  inas- 
much as  it  continued  unabated  when  an  exclusively  animal  diet  was  employed. 

3d.  The  excessive  glycosuria  going  on  in  this  case  was  effected  mainly,  or 
entirely,  in  the  liver ;  not  in  the  muscles  or  the  other  viscera.  For  (a)  when 
the  mcrphia  was  introduced  into  the  liver  by  the  portal  vein  it  reduced  the 
sugar  to  nil,  but  had  little  effect  on  the  other  viscera,  while  (b)  when  intro- 
duced into  the  general  circulation  hypodermatically,  it  diminished  the  amount 
of  sugar  but  little,  but  had  a  decided  effect  on  the  other  viscera,  especially 
the  central  nervous  system. 

4th.  In  this  instance  if  the  diabetes  was  of  nervous  origin,  the  seat  of  the 
process  appears  to  have  been  at  any  rate  in  the  liver,  not  in  the  central 
nervous  system. 

The  Occurrence  of  Albuminuria  in  Diabetes. 

Incited  by  the  statement  of  Stokvis,  that  albuminuria  is  a  very  common 
complication  of  diabetes,  Pollatschek  (Zeitsch.f.  Min.  Med.,  B.  xii.  H.  1, 379) 
undertook  some  investigations  on  the  subject.  He  found  that  of  2877  persons 
whose  urine  was  examined  in  one  of  the  chemical  laboratories  in  Carlsbad, 
1187  had  glycosuria,  and  437  of  these  latter  had  albuminuria  also.  Or,  in 
other  words,  37  per  cent,  of  the  cases  of  diabetes  had  albumen  in  the  urine. 
He  found,  too,  that  albumen  occurred  oftener  in  urine  that  contained  over  0.5 
per  cent,  of  sugar. 

On  the  "Starch-converting"  Ferment  in  Human  Urine. 
Breusing  publishes  in  Virchow's  Archiv,  B.  cvii.  H.  1,  186,  his  experi- 
ments relating  to  the  statement  of  Holovtschiner  made  in  April,  lSSii,  that 
there  existed  in  urine  a  ferment  capable  of  transforming  starch  into  dextrine 
and  sugar. 


234 


PROGRESS  OF   MEDICAL  SCIENCE. 


He  mixed  equal  portions  of  urine  and  of  a  one  per  cent,  starch  solution, 
and  subjected  them  to  a  temperature  of  37.5°  C.  for  twenty-four  hours  or  less. 
Although  he  found  at  the  end  of  this  time  that  the  starch  had  completely- 
disappeared,  he  was  in  no  instance  able  to  detect  sugar  by  any  test  employed. 

In  Trommer's  test  the  suboxide  of  copper  was,  it  is  true,  precipitated  after 
boiling  for  some  time,  but  the  author  properly  considers  this  no  proof  of  the 
presence  of  glucose.  Although  the  experiment  was  modified  in  various  ways, 
and  the  urine,  both  of  healthy  persons  and  of  those  suffering  from  various 
diseases,  was  utilized,  the  result  was  always  the  same. 

It  was  interesting  to  observe  that  the  starch-converting  agent  was  present 
in  the  urine  of  diabetic  patients.  It  was  also  detected  in  the  fluid  aspirated 
from  a  case  of  ascites. 

Breusing  is  of  the  opinion  that  the  ferment  converts  the  starch  only  into 
one  of  the  substances  produced  before  the  final  change  into  glucose  takes 
place. 

On  the  Correlation  of  the  Secreta  and  Excreta  of  the 

Organism. 

At  the  suggestion  of  Professor  Eiegel,  Sticker  and  Hubner  {Zeitsch.  f» 
klin.  Med.,  B.  xii.  H.  1  and  2,  114)  have  attempted  to  discover  whether  the 
absence  of  free  hydrochloric  acid  in  the  gastric  contents  in  cases  of  carcinoma 
of  the  stomach,  could  be  explained  in  any  way  by  testing  the  degree  of  acidity 
of  the  urine  at  different  hours  in  the  day.  After  a  series  of  extended  researches 
they  reach  the  following  conclusions  : 

1.  The  reaction  of  the  urine  is  subject  to  physiological  variations,  which 
show  a  constant  dependence  on  certain  processes  going  on  in  the  organism. 

2.  The  most  important  of  these,  in  this  connection,  is  the  secretion  of  the 
digestive  juices,  especially  those  of  the  stomach  and  pancreas.  Muscular 
action,  and  perhaps  menstruation  and  psychical  action,  is  of  less  importance. 

3.  If  the  various  processes  referred  to  are  not  going  on,  the  urine  preserves 
during  this  time  and  without  variation  the  usual  mean  of  the  acidity  of  the 
twenty-four  hours. 

4.  The  absolute  acidity  of  the  urine  passed  during  the  twenty-four  hours  is 
constant  for  each  individual  under  an  approximately  uniform  state  of  the 
nutrition.  It  varies  for  different  individuals,  both  in  physiological  and  patho- 
logical conditions. 

5.  The  acidity  of  the  urine  is  chiefly  or  entirely  dependent  on  the  formation 
of  free  hydrochloric  acid  in  the  organism,  and  its  retention  there.  If  it  is 
artificially  or  accidentally  (as  by  vomiting,  etc.)  removed,  the  urine  suffers  as 
regards  its  absolute  acidity. 

6.  The  graphic  curve,  showing  the  variations  of  the  acidity  of  the  urine  at 
different  hours  in  the  day,  is  in  consequence  of  the  predominating  influence 
of  hydrochloric  acid  in  the  reaction  of  the  urine,  in  a  certain  sense  the  expres- 
sion of  the  intensity  of  the  digestive  power  of  the  stomach. 

7.  This  curve  has,  however,  no  semeiotic  value  in  pathological  conditions, 
since  other  processes  in  the  organism,  especially  the  secretion  of  the  pancre- 
atic juice,  may  disturb  or  destroy  its  typical  appearance. 


MEDICINE. 


235 


On  Digestive  Ferments  in  Normal  and  Pathological  Urines. 

Following  the  investigations  of  Holvotschiner,  who  found,  both  in  normal 
and  pathological  urine,  an  amylolytic  ferment  having  the  power  of  converting 
starch  in  solution  into  both  dextrin  and  sugar,  Breusing  (  Vir chow's  Archiv, 
vol.  107.  p.  186)  made  a  series  of  experiments,  using  more  exact  methods  than 
the  first  observer  for  the  detection  of  the  sugar. 

He  found  that  on  mixing  varying  quantities  of  a  one  per  cent,  solution  of 
boiled  starch  with  urine  and  keeping  the  mixture  for  twenty-four  hours  at  a 
temperature  of  37.5°  C,  no  starch  was  to  be  found  with  the  iodine  test  at  the 
end  of  that  time.  Iodine  gave  a  brown,  yellowish,  or  rose  color  when  added 
to  the  solution.  With  Moore's  test — the  only  one  Holvotschiner  had  used— 
a  distinct  brown  coloration  appeared,  but  on  more  careful  examination  it  was 
found  that  this  did  not  arise  from  the  presence  of  sugar.  Trommer's  test  was 
reduced  only  after  boiling  for  two  to  four  minutes  (glucose  reduces  it  at  once 
and  before  the  boiling-point  is  reached),  and  the  fermentation  test — the  most 
conclusive  of  all  we  have  for  sugar — gave  absolutely  negative  results.  No 
difference  could  be  observed  in  the  action  of  pathological  or  normal,  or  of 
night  or  day,  urines.  To  prove  that  the  amylolytic  action  is  really  due  to 
the  presence  of  a  ferment,  Breusing  separated  the  ferment  by  precipitation 
with  an  excess  of  absolute  alcohol,  in  the  usual  way,  and  found  that  it  acted, 
when  alone,  upon  solutions  of  starch  the  same  as  it  did  when  in  the  urine. 
Boiling  the  urine  destroyed  its  action. 

He  presumed  that  in  diabetes  this  ferment  might  possibly  be  absent  on 
account  of  its  having  been  consumed  in  the  body  in  the  conversion  of  starches 
to  glucose.  But  the  examination  of  a  specimen  of  diabetic  urine,  containing 
5.8  per  cent,  of  glucose,  showed  it  to  act  even  more  powerfully  and  rapidly 
than  normal  urine,  indicating  the  probable  presence  of  a  large  quantity  of 
this  ferment. 

[These  experiments  show  that  urine  contains  an  amylolytic  ferment  capable 
of  converting  boiled  urine  into  some  of  the  preliminary  stages  of  glucose, 
namely,  the  various  dextrines  known  as  erythro-  and  achroo-dextrines,  whose 
presence  was  denoted  by  the  various  colors  of  rose  and  yellow  and  brown  as- 
sumed by  the  solution  on  the  addition  of  iodine,  but  that  the  conversion  is 
not  carried  to  the  final  product — i.  e.,  glucose.] 

It  is  interesting  to  note,  in  this  connection,  that  Mya  and  Belfanti  ( Cen- 
tralblatt  f.  klin.  Med.,  1886,  No.  42)  found  that  in  28  cases  of  Bright's  disease  (4 
acute,  24  chronic),  the  trypsin  normally  found  in  urine  was  invariably  absent, 
while  pepsin  was  nearly  always  present.  In  febrile  and  physiological  albu- 
minuria, on  the  other  hand,  the  trypsin  was  never  absent.  This  difference 
might,  in  doubtful  cases,  serve  as  a  means  of  differential  diagnosis.  The 
method  of  determination  employed  consisted  in  soaking  2  grammes  of  fibrin 
in  500  c.  c.  of  urine  for  three  hours,  then  pressing  out  the  excess  of  urine  and 
transferring  the  fibrin  to  a  1 :  5  per  cent,  solution  of  borax,  and  keeping  it  thus 
at  a  temperature  of  37.5°  C.  for  twenty-four  hours.  The  borax  solution  pre- 
vents putrefaction.  One-half  of  the  fibrin  was  used  to  determine  the  trypsin 
and  one-half  for  the  pepsin.  After  a  twenty-four  hours'  digestion,  the 
amount  of  fibrin  remaining  after  washing  and  drying  determined  the  amount 
digested. 


236 


PROGEESS   OF   MEDICAL  SCIENCE. 


Reducing  Substances,  other  than  Glucose,  in  Diabetic  Urine. 

Struck  with  the  discrepancies  in  the  quantitative  results  obtained  by  sub- 
jecting the  same  specimen  of  diabetic  urine  to  the  fermentation,  the  copper- 
oxide  reduction,  and  polariscopic  tests,  respectively,  Leo  (  Virchow's  Archiv, 
vol.  107,  p.  99)  endeavored  to  discover  the  source  of  these  errors.  He  suc- 
ceeded, after  removing  all  the  ordinary  reducing  substances,  as  uric  acid, 
creatinin,  coloring  matters,  etc.,  in  finding  a  new  substance  belonging  to  the 
sugar  series,  and  with  the  power  of  strongly  reducing  the  copper-oxide  solu- 
tions, whether  as  Fehling's  or  Trommer's  tests.  This  new  substance,  for 
which  no  name  has  as  yet  been  proposed,  is  isomeric  with  glucose.  It  turns 
the  polarized  ray  to  the  left  — 26.73°,  and  hence,  when  present,  makes  the 
polariscopic  readings  for  diabetic  urine  indicate  a  lower  percentage  of  glucose 
than  is  actually  present.  It  reduces  copper-oxide  solutions ;  10  c.  c.  of 
Fehling's  solution  corresponding  to  0.1242  grain,  or  one  molecule,  correspond- 
ing to  2.012  molecules  of  sugar.  In  using  this  test,  therefore,  larger  quantities 
of  glucose  than  are  actually  present  will  apparently  be  obtained.  It  is  not 
fermentable,  and  this  property  distinguishes  it  from  all  other  sugar-like  bodies 
found  in  the  urine,  and  at  the  same  time  proves  the  value  of  fermentation  as 
a  test  for  glucose,  for,  besides  glucose,  only  levulose,  whose  occurrence  is  very 
rare,  is  fermentable. 

This  substance  was  found  in  3  out  of  21  cases  of  diabetes.  It  did  not  occur 
in  a  large  number  of  normal  urines  examined. 

Serum-albumin  in  Normal  Urine. 
Posner  (Virchow's  Archiv,  vol.  104,  p.  1)  has  made  careful  investigations 
to  settle  this  much-disputed  point,  with  the  result  of  showing  that  a  minimal 
amount  of  serum-albumin  is  a  constant  constituent  of  normal  urine.  This  is 
important  in  view  of  the  significance  which  is  attributed  by  many  to  the  de- 
tection of  almost  infinitesimal  quantities  of  albumin  by  such  delicate  reagents 
as  the  potassio-mercuric  iodide,  picric  acid,  etc.  When  we  consider  the  con- 
stant presence  in  the  urine  of  albuminoid  anatomical  elements,  it  is  not 
surprising  that  their  disintegration  and  solution  should  liberate  an  amount  of 
albumin  which,  though  small,  is  still  appreciable. 


SURGERY. 


In  Europe, 
under  the  charge  of 
FEEDEEICK  TEEVES,  F.E.C.S., 

SURGEON  TO,  AND  LECTURER  ON  ANATOMY  AT,  THE  LONDON  HOSPITAL. 


Eecent  Surgical  Literature. 
The  last  new  volume  of  the  Dictionnaire  Encyclopedique  des  Sciences  Medicates 
runs  from  "  Uri "  to  "  Ute."    The  article  on  the  urinary  passages  is  completed. 
Under  the  heading  of  "The  General  Pathology  of  the  Urinary  Passages,"  M. 


SURGERY. 


237 


Rochard  discusses  retention,  incontinence,  and  extravasation  of  urine,  and 
urinary  abscess.  The  matter  is  a  little  spun  out.  The  paper  that  follows — 
"  A  Monograph  on  Urinary  Fistulae,"  by  M.  Monod,  is  the  best  in  the  volume. 
He  deals  with  fistulse  of  the  kidney,  ureter,  bladder,  and  urethra,  and  with 
fistulse  in  women.  The  article  is  very  complete  and  is  a  masterpiece  of  elab- 
orate work.  A  very  short  paper  on  calculi,  by  M.  Derboullet,  deals  merely 
with  the  general  chemical  characters  of  urinary  stones.  The  rest  of  the 
volume  is  taken  up  with  the  article  "  Urines"  and  the  commencement  of  the 
series  of  papers  on  the  uterus. 

Die  Allgemeine  Chirurgische  Pathologie  und  Therapie,  by  Drs.  Billroth  and 
Winiwarter  (Berlin,  1887).  This  is  a  new  edition  (the  thirteenth)  of  Bill- 
roth's  well  known  work  on  general  surgical  pathology  and  treatment.  The 
book  has  been  revised  by  Dr.  Winiwarter  and  brought  up  to  date.  It  still 
remains  the  best  text-book  on  surgical  pathology. 

Etudes  Experimentales  et  Cliniques  sur  la  Tuberculose,  edited  by  M.  Verneuil 
(Paris,  1887).  This  is  the  first  fasciculus  of  a  work  on  tuberculosis  and  is  the 
outcome  of  an  organized  effort  to  solve  the  mystery  of  this  affection.  It  con- 
tains papers  by  a  great  many  authors,  and  the  whole  volume  is  filled  with 
original  matter  of  the  greatest  value.  The  papers  of  the  greatest  surgical  in- 
terest are  the  following:  Lannelongtje,  on  "External  Congenital  Tubercu- 
losis;" Becltjs,  on  "Primitive  Tuberculosis  of  the  Scrotum;"  Valude,  on 
"Ocular  Tuberculosis;"  Demarr  and  Verneuil,  on  "The  Generalization 
of  Tuberculoses  after  the  Ablation  of  a  Primary  Tubercular  Disease ;"  Ver- 
chere,  on  "  The  Treatment  of  Scrofulous  Neck." 

Die  Typischen  Operationen,  by  Dr.  Emil  Rotter  (Munich,  1887).  This  is 
a  very  compact  little  work  on  the  chief  operations  in  surgery.  It  is  very 
ingeniously  arranged  and  is  intended  in  reality  to  be  a  handbook. 

The  chief  points  of  each  operation  are  given  clearly  and  the  descriptions 
are  brief  but  good.  The  anatomy  of  each  operation  is  given  in  detail,  and 
excellent  diagrams  of  the  stumps  of  several  amputations  are  given  so  as  to 
show  the  position  of  the  bleeding  points. 

Anleitung  zur  Wundbehandlung,  by  Dr.  Schaechter  (Wiesbaden,  1887). 
This  large  work  forms  a  complete  treatise  upon  the  treatment  of  wounds  and 
is  a  production  of  conspicuous  merit.  The  author  deals  in  the  first  place  with 
the  pathology  of  wound-healing  and  thus  introduces  the  inevitable  bacillus. 
Then  follow  chapters  on  sepsis  and  the  complications  of  wound-healing.  The 
main  part  of  the  volume  is  occupied  by  the  treatment  of  wounds  in  general 
and  of  wounds  of  special  parts.  The  list  of  materials  for  dressing  described 
under  the  heading  of  general  treatment  is  remarkable  and  alarming. 

Tumeurs  de  I'Ombilic,  by  Dr.  Villar  (Paris,  1887).  This  is  a  work  peculiar 
to  French  industry,  a  substantial  volume  on  tumors  of  the  umbilicus  (exclud- 
ing hernia).    The  following  is  the  classification  adopted  by  the  author : 

Benign.  Vascular:  angioma,  lymphocele.  Granuloma:  the  fungus  of  the 
newly  born.  Adenoma:  intestinal,  gastric.  Cysts:  sebaceous,  dermoid. 
Fibro-papilloma.  Myxoma. 


238 


PROGKESS   OF   MEDICAL  SCIENCE. 


Malignant.    Sarcoma,  epithelioma,  carcinoma. 

Nearly  ninety  illustrations  are  given.    There  is  an  exhaustive  bibliography 
The  illustrations  are  very  poor. 

Die  Allgemeine  Pathologie  oder  die  Lehre  von  den  Ursachen  und  den  Wesen  der 
Kranhheitsprocessen,  by  Dr.  Edwin  Klebs  (Jena,  1887).  This  is  the  first 
volume  of  an  ambitious  work  (on  general  pathology  or  the  science  of  the 
causes  and  action  of  disease-processes).  The  volume  is  disappointing  because 
nearly  the  whole  of  it  is  occupied  with  descriptions  of  bacteria.  The  author 
deals — in  the  500  pages  of  this  volume — with  such  diseases  as  are  conspicu- 
ously associated  with  microorganisms.  The  work  is  admirably  done  and  the 
illustrations  are  excellent. 

Das  Venerische  Geschwiir,  Vorlesungen  uber  dessen  Pathologie  und  Therapie,  by 
Dr.  E.  Lang  (Wiesbaden,  1887).  This  admirable  work  on  the  pathology  and 
treatment  of  venereal  ulcers  comes  from  the  pen  of  a  well-known  author. 
The  subject  is  exhaustively  dealt  with  and  the  chapters  on  exceptional  vene- 
real sores  and  on  differential  diagnosis  are  especially  valuable.  The  author's 
conclusions  are  founded  upon  ample  clinical  material  and  a  wide  experience. 

Uber  die  Excision  der  Syphilitischen  Initials Merose,  by  Dr.  J.  Bohn  (Breslau, 
1886).  This  dissertation  discusses  the  question  of  the  value  of  excision  of  the 
primary  sore  in  syphilis.  The  author  is  of  opinion  that  the  measure  may 
entirely  prevent  the  development  of  constitutional  syphilis.  He  allows  that 
the  treatment  is  not  always  successful,  and  is  unable  to  give  the  data  upon 
which  the  chances  of  failure  may  be  estimated.  The  work  is  of  special  value 
as  giving  a  full  bibliography  of  the  whole  of  this  vexed  question. 

Die  Epistaxis  und  ihre  Behandlung,  by  Dr.  Baumgarten  (Vienna,  1886). 
This  is  an  elaborate  treatise  upon  the  pathology  and  treatment  of  epistaxis. 
The  account  of  the  anatomy  of  the  nasal  mucous  membrane  is  very  full.  The 
etiology  of  epistaxis  is  fully  dealt  with,  as  is  also  the  question  of  treatment. 
In  the  latter  direction  it  cannot  be  said  that  any  very  new  matter  is  introduced. 

DelV Artreetomia  Pargiale  e  Totale,  by  D.  E.  Paoii  (Turin,  1887).  A  full 
account  is  provided  of  the  operation  of  arthrectomy.  Details  are  given  with 
regard  to  each  individual  point.  The  more  practical  part  of  the  work  is 
founded  upon  an  account  of  20  cases.  Among  this  number  were  14  cases  of 
strumous  joint  disease.  13  of  these  ended  in  cure,  with  useful  limbs,  and  1 
died  of  general  tuberculosis.  The  author  regards  total  synovial  arthrectomy 
as  an  excellent  means  of  promoting  fibrous  ankylosis.  He  applied  it  with 
success  in  a  case  of  chronic  synovitis  with  loose  bodies  in  the  joint  and  undue 
mobility  of  the  limb. 

Transactions  of  the  Academy  of  Medicine  in  Ireland,  Vol.  IV.  (Dublin,  1887). 
In  addition  to  certain  surgical  papers  that  have  been  already  noticed,  the 
present  volume  contains  the  following  contributions:  "The  Advantages  of 
the  Principle  of  Dry  Dressings  in  Antiseptic  Surgery,"  by  Dr.  Banks;  "The 
Surgery  of  the  Suakim  Expedition,"  by  Dr.  Tobin;  "Electrolysis  in  the 
Treatment  of  Urethral  Stricture,"  by  Mr.  Hayes. 


SUKGERY. 


Die  una  speciale  medicazione  abortiva  deW  erisipla,  by  Dr.  Arxict  (Rome, 

1886)  .  In  this  small  but  ambitious  work  the  author  claims  to  have  discovered 
the  abortive  treatment  of  erysipelas.  He  makes  use  of  an  alcoholic  solution 
(apparently  1  in  1)  of  carbolic  acid.  This  is  painted  freely  over  the  skin  on 
and  about  the  margin  of  the  spreading  erythema.  The  solution  is  applied, 
not  only  to  the  reddening  edge,  but  also  to  the  sound  skin  for  a  few  centimetres 
beyond  that  edge.  Two  or  three  applications  are  made  within  a  few  hours. 
No  local  trouble  is  said  to  follow.  The  pain  that  arises  is  checked  by  the  use 
of  cold.  He  thinks  the  paint  acts  partly  as  a  caustic,  partly  as  an  antiseptic. 
He  has  treated  12  cases  of  erysipelas  by  this  means,  and  2  examples  of  lymph- 
angitis.   In  all  an  immediate  and  rapid  cure  followed. 

Die  Pathologie  und  Therapie  der  Gelenhentziindungen ,  by  Prof.  Max  Schul- 
ler  (Vienna,  1887).  A  short,  but  excellent  and  complete  account  of  inflamma- 
tory affections  of  the  joints.  Prof.  Schiiller's  valuable  work  upon  scrofulous 
joint  disease  is  well  known.  This  monograph  embraces  the  whole  subject.  It 
is  well  written,  well  arranged,  and  full  of  original  matter.  It  is  up  to  date, 
and  concludes  with  an  exhaustive  bibliography. 

St.  Thomas's  Hospital  Reports,  vol.  xv,  (London,  1887).  The  following  are 
the  chief  surgical  papers  :  "  Three  Cases  of  Nerve  Suture,"  by  Sir  William 
MacCormac.  In  one  case  the  ulnar  nerve  was  united  by  suture  six  years 
after  division.  Restoration  of  nerve  function  followed.  "  Pre-prostatic 
Puncture  of  the  Urethra,"  by  Mr.  Makixs,  a  valuable  paper,  giving  an 
anahsis  of  46  cases.  "Neurectomy  of  the  Second  Division  of  the  Fifth 
Nerve,"  by  Mr.  Cluttox.  The  operation  was  performed  for  intractable  neu- 
ralgia. "  Nerve-stretching  of  the  Inferior  Dental  Nerve  for  Neuralgia,"  by 
Mr.  Berxard  Pitts. 

Westminster  Hospital  Reports,  vol.  ii.  (London,  1887).  The  two  surgical 
papers  in  this  volume  are  the  following  :  (1 )  "Solid  Abdominal  Tumors,"  by 
Mr.  Cowell — an  account  of  three  interesting  cases.  Two  were  ovarian  fibro- 
mata, and  the  third  a  fibroma  of  the  round  ligament.  (2)  "Rheumatic  Os- 
teitis," by  Mr.  Macxamara.  An  elaborate  and  valuable  paper,  with  two 
illustrative  cases. 

Diseases  of  Bones  and  Joints,  by  Mr.  Macxamara  (third  edition,  London, 

1887)  .  In  the  present  edition  many  chapters  have  been  rewritten,  much  new 
matter  and  many  excellent  illustrations  have  been  added,  and  the  book  is 
brought  well  up  to  date. 

Bacteria  axd  Tubercular  Abscess. 

Dr.  Farre  {Deutsche  med.  Wochenschrift,  1880,  No.  84)  has  published  an 
important  paper  on  this  subject.  He  has  examined  30  cases  of  cold  or  tuber- 
cular abscess.  In  only  a  very  few  instances  were  bacilli  found  in  the  pas. 
In  the  cases  in  which  no  bacilli  were  detected  cultivation  experiments  led  to 
nothing.  Small  quantities  of  the  pus  that  was  free  from  bacilli  were  injected 
into  animals  with  the  usual  precautions.  In  every  case  tuberculosis  followed. 
Here,  then,  is  an  example  of  tuberculosis  produced  by  inoculation  with  a 


240 


PROGBESS   OF   MEDICAL  SCIENCE. 


material  that  contained  no  tubercle  bacilli,  and  yielded  none  of  the  cultiva- 
tion. The  paper  is  largely  occupied  by  the  author's  theories  to  meet  this 
fact.  Incidentally  the  following  data  are  given  for  the  separation  micro- 
scopically of  tubercular  pus  from  simple  inflammatory  pus.  In  the  latter  the 
cells  are  long  and  well  preserved ;  there  is  little  or  no  debris,  pyogenic  cocci 
are  present.  In  the  former  the  cells  are  ill  formed,  many  are  wasted.  There 
is  much  fatty  debris,  and  no  cocci. 

The  Use  of  Iodol. 

Dr.  F.  J.  Pick  ( Vierteljahrsschrift  fur  Dermatologie  und  Syphilis,  1886,  p. 
583)  has  used  iodol  in  93  cases  with  the  following  results.  It  is  excellent  in 
the  treatment  of  catarrhal  affections  of  the  genitals,  especially  in  women.  It 
is  also  of  considerable  use  in  moist  condylomata,  but  is  of  less  value  in  the 
treatment  of  venereal  ulcers.  It  has  proved  of  but  moderate  value  in  the 
dressing  of  gummatous  ulcers  and  buboes. 

The  drug  has  been  given  internally,  but  without  any  benefit.  The  author 
points  out  that  when  iodol  is  given  internally  the  iodine  reaction  is  obtained 
in  the  urine.  No  such  reaction  is  observed  after  local  application  of  the  drug. 

A  New  Micrococcus. 

Professor  Manfredi  (Fortschritte  der  Medicin,  Bd.  iv.  p.  713)  claims  to 
have  added  another  coccus  to  the  already  bewildering  list  of  microorganisms. 

The  author  founds  his  discovery  upon  two  fatal  cases  of  croupous  pneu- 
monia. In  the  sputa  in  these  cases  he  found,  in  addition  to  the  usual  pneu- 
monic bacillus,  another  specific  bacillus  of  extraordinary  properties.  It  was 
of  oval  shape,  and  was  easily  cultivated  upon  gelatine.  The  cultivation  area 
was  at  first  a  delicate  blue,  and  then  a  pearl  gray,  with  sinuous  margins. 
The  inoculation  of  dogs  and  rabbits  led  to  a  fatal  issue  in  seven  to  twelve  days. 
Before  death  there  occurred  an  enormous  swelling  of  the  spleen,  and  great 
hypertrophy  of  the  lymphatic  glands.  The  tumors  were  composed  of  granu- 
lation-like tissue,  and  rapidly  caseated.  The  lungs  were  the  seat  of  pneu- 
monia, and  also  of  like  granular  masses. 

The  author  terms  the  bacillus  "  The  micrococcus  of  the  progressive  lymph- 
oma," and  considers  it  the  cause  of  the  neoplasms  that  developed  in  the 
animals'  bodies. 

The  Incubation  Stage  of  Hydrophobia. 

Dr.  Bauer  {Centralblatt  fur  Chirurgie,  January  1,  1887)  deals  with  537 
examples  of  this  disease  in  man,  in  which  the  period  of  incubation  is  stated. 
10  cases  are  rejected  as  doubtful,  and  17  in  which  it  is  asserted  that  the  incu- 
bation stage  extended  beyond  15  months.  In  the  remaining  510  cases  the 
average  incubation  period  is  72  days.  So  far  as  can  be  shown,  the  primary 
treatment  of  the  wound  has  no  effect  upon  the  duration  of  this  period.  The 
following  factors  in  influencing  the  length  of  the  period  between  the  time  of 
the  bite  and  the  appearance  of  symptoms  are  evident. 

Sex.  In  males  the  average  period  is  80  days;  in  females,  65  days. 

Age  has  considerable  influence,  the  stage  being  shortened  by  20  days  in 
patients  under  14  years  of  age. 


SURGERY. 


241 


The  Infecting  Animal. 

Bite  from  wolf,   49  cases,  average  incubation  stage,  39  days. 
'«      "    dog,  293     "         "  "  "     73  " 

"     "    fox,      2    "        "  "  "    33  " 

"  .  "    cat,     31    "        "  "  "    80  " 

"      •'    cow,     lease,       "  "  "     30  « 

The  Treatment  of  Erysipelas. 

Dr.  Nussbaum  (Allg.  Wiener  med.  Zeitung,  1887,  No.  1)  advises  ichthyol 
for  the  treatment  of  erysipelas  migrans.  It  is  applied  in  the  form  of  an  oint- 
ment, composed  of  ichthyol  and  vaseline,  in  equal  parts.  This  is  applied  over 
the  spreading  margin.  The  part  is  then  covered  with  a  10  per  cent,  salicylate 
wadding.   The  measure  has  been  tried  in  5  cases,  with  uniformly  good  results. 

Cancer  of  the  Breast. 

Mr.  H.  T.  Butlin  [British  Medical  Journal,  1887,  vol.  i.  p.  436)  gives  the 
result  of  the  investigation  made  upon  this  subject  by  the  Collective  Investiga- 
tion Committee  of  the  British  Medical  Association.   The  returns  number  210. 

1.  The  influence  of  mastitis  in  the  production  of  cancer.  Out  of  174  instances 
previous  inflammation  or  abscess  of  the  affected  breast  had  been  noted  in  27 
cases.  No  such  disturbance  had  been  noted  in  the  remaining  147  cases. 
From  the  returns  it  may  be  gathered  that  a  previous  mastitis  plays  a  quite 
unimportant  part  in  the  etiology  of  cancer.  In  nearly  one-half  of  the  cases 
20  years  had  elapsed  between  the  inflammation  and  the  appearance  of  the 
tumor.  The  form  of  inflammation  that  would  seem  to  predispose  to  cancer 
is  one  that  is  continuous,  or  liable  to  frequent  recurrence,  or  the  seat  of  a 
chronic  irritation. 

2.  The  influence  of  inheritance.  Out  of  184  cases,  in  116  there  was  no  family 
history  of  cancer ;  in  68  there  was.  The  manner  of  distribution  in  the  68 
cases  was  as  follows :  44  patients  had  only  one  cancerous  relative,  19  had  2, 
3  had  3,  and  2  had  4  cancerous  relatives  apiece. 

Thus  the  68  patients  had  among  them  no  less  than  99  cancerous  relatives. 

In  only  30  instances  were  the  parents,  grandparents,  or  great-grandparents 
of  the  patient  cancerous. 

There  is  thus  a  history  of  cancer  in  the  direct  line  of  descent  in  no  less  than 
20.6  per  cent,  of  the  cases. 

3.  The  influence  of  diet.  Out  of  194  returns  123  patients  are  stated  to  be 
moderate  feeders,  57  small  feeders,  and  12  large  feeders.  The  tables  do  not 
support  the  statement  that  cancer  is  more  common  in  large  eaters  of  meat. 

4.  The  influence  of  locality.  The  returns  under  this  heading,  as  well  as 
under  the  previous  one,  are  scant  and  unsatisfactory.  Town,  as  compared 
with  country,  and  high  elevation,  as  compared  with  low,  would  appear  to 
have  no  influence  in  the  etiology  of  cancer. 

The  returns  agree,  to  a  great  extent,  with  the  conclusions  of  Mr.  Haviland, 
who  finds  the  lowest  rates  of  mortality  from  cancer  in  those  parts  of  Enlgland 
and  Wales  which  are  composed  of  the  hardest  and  most  elevated  rocks,  or 

NO.  CLXXXVII. — JULY,  1887.  16 


242 


PEOGEESS   OF   MEDICAL  SCIENCE. 


the  most  absorbent  (like  the  oolite  and  chalk) ;  and  the  highest  rates  in  the 
sheltered  and  low-lying  grounds  which  are  composed  of  crag,  alluvium,  and 
clay. 

Excision  of  the  Kxee. 

Me.  Morrant  Baker  {British  Medical  Journal,  1887,  vol.  i.  p.  321)  points 
out  the  difficulty  of  maintaining  the  bones  in  position  after  the  operation,  and 
proposes  the  following  procedure,  which  he  has  carried  out  with  success : 

After  the  bone-ends  have  been  resected  the  tibia  and  femur  are  fixed 
together  by  means  of  two  strong  steel  pins.  These  are  made  to  transfix  the 
tibia  and  bury  themselves  in  the  femur.  They  are  so  introduced  that  they 
cross  one  another,  St.  Andrew's  cross  fashion.  The  tibial  end  of  the  pin  is 
left  projecting  beyond  the  skin.  The  pins  are  removed  as  soon  as  they 
become  loose.  This  may  occur  at  the  end  of  a  few  days,  or  not  for  a  period 
of  from  four  to  seven  weeks.    The  paper  concludes  with  14  illustrated  cases. 

Mr.  Howard  Marsh  [Ibid.,  p.  389)  favorably  considers  Mr.  Baker's  oper- 
ation. Mr.  Marsh  recommends  the  splint  described  in  Gant's  Practice  of  Sur- 
gery, 2d  edition,  vol  i.  p.  16,  and  employs  bone  pins  instead  of  those  made 
of  steel.  Ordinary  bone  knitting  needles  are  used.  The  holes  in  the  tibia 
are  bored  by  means  of  a  bradawl,  the  ends  of  the  knitting  needle  are  sharp- 
ened, and  when  they  have  transfixed  the  tibia  are  driven  into  the  femur  by  a 
few  taps  from  a  mallet.  The  pins  are  cut  short,  and  are  left  permanently  in 
situ.  Mr.  Marsh  has  used  these  bone  pins  combined  with  Mr.  Gant's  splint 
in  nine  cases. 

Internal  Derangements  of  the  Knee-joint. 

Professor  Annanda.ee  [British  Medical  Journal,  1887,  vol.  i.  p.  319) 
includes  the  following  conditions  under  this  term  (excluding  "loose  carti- 
lages"): 1.  Displacements  of  the  semilunar  cartilage.  2.  Growths  in  the 
interior  of  the  joint.    3.  Growths  from  the  bone  protruding  into  the  joint. 

1.  One  or  other  of  the  semilunar  cartilages  (most  frequently  the  interna  l  one) 
is  liable  to  be  displaced  and  to  interfere  with  the  joint  movements.  The  dis- 
placement is,  as  a  rule,  slight.  The  anterior  attachments  of  the  cartilage  are 
those  which  are  most  frequently  separated.  The  displacement  may  take  place 
suddenly,  due  to  a  twist  or  wrench,  or  may  occur  gradually  from  the  excessive 
use  of  certain  movements,  especially  kneeling.  Displacement  of  the  inner 
cartilage  is  usually  produced  when  the  leg  is  rotated  outward,  and  of  the  outer 
cartilage  when  it  is  rotated  inward.  The  operation  the  author  adopts  in  this 
condition  is  the  following :  An  incision  is  made  over  the  cartilage  in  a  hori- 
zontal direction,  extending  backward  from  the  edge  of  the  patellar  ligament 
about  three  inches.  The  joint  is  opened.  The  cartilage  is  replaced  and  fixed 
in  position  by  catgut  sutures  that  take  hold  of  the  periosteum  and  fascia  about 
the  upper  end  of  the  tibia. 

2.  Three  examples  are  given — two  of  lipomata  and  one  of  myeloid  sarcoma. 
In  the  former  a  fatty  growth  from  the  synovial  membrane  over  one  of  the 
semilunar  cartilages  was  present.  It  was  removed  and  perfect  recovery  fol- 
lowed. The  sarcomatous  growth  was  the  size  of  a  horse  bean,  and  grew  from 
the  synovial  membrane.    It  was  successfully  removed.    In  these  three  cases 


SUEGEKY. 


243 


symptoms  were  present  that  closely  resembled  those  due  to  displaced  semi- 
lunar cartilage. 

3.  In  this  case — a  solitary  example — a  bony  growth,  due  to  chronic  rheu- 
matic arthritis,  grew  from  the  lower  end  of  the  femur.  It  caused  much  im- 
pairment of  the  movements  of  the  joint.  It  was  removed  and  a  successful 
result  followed. 

Amputation  in  Diabetic  Gangrene. 

Professor  Konig  [Centralblatt  fur  Chirurgie,  No.  13, 1887)  has  contributed 
an  interesting  paper  on  this  subject.  He  points  out  that  diabetic  patients  are 
liable  to  a  low  form  of  inflammation ;  that  their  tissues  present  a  favorable 
nidus  for  the  development  of  microorganisms,  and  show  a  ready  disposition  to 
necrose.  He  suggests  that  in  all  cases  of  apparently  spontaneous  gangrene, 
or  of  gangrene  from  trifling  causes,  the  urine  should  be  examined  for  sugar. 

In  inflammatory  affections,  in  necrosis,  and  in  gangrene  occurring  in  dia- 
betic subjects,  the  first  and  most  persistent  treatment  should  be  by  the  use  of 
antidiabetic  measures.  Amputation  should  not  be  entertained  until  the 
diabetic  symptoms  are  retrograde.  If  in  spite  of  treatment  and  careful  local 
antiseptic  measures,  the  local  and  general  symptoms  do  not  improve,  then 
operation  must  be  undertaken  as  a  possible  means  of  saving  the  patient's  life. 

Seduction  of  Shoulder  Dislocations. 

Dr.  Macleod  (British  Medical  Journal,  1887,  vol.  i.  p.  507)  claims  for  the 
method  of  reduction  he  describes  the  following  advantages.  It  is  easy,  rapid, 
painless,  needs  no  anaesthetic,  apparatus,  or  assistants,  and  probably  does  no 
injury  to  the  joint. 

The  method  may  be  described  as  lateral  extension  in  the  supine  position. 

Place  the  patient  on  his  back  on  the  floor  with  the  arm  at  right  angles  to 
the  body,  and  tell  him  to  lie  still  and  make  no  effort.  The  surgeon,  sitting 
on  the  floor  at  right  angles  to  the  patient's  body,  places  his  heel  in  the  axilla, 
quietly  takes  the  limb  by  the  wrist  and  upper  arm,  and  pulls  in  a  line  at  right 
angles  to  the  line  of  the  trunk,  at  first  gently  and  then  gradually  increasing 
up  to  a  force  of  a  few  pounds — the  arm  being  still  on  the  floor,  or  but  slightly 
raised  from  it.  As  reduction  may  take  place  without  any  intimation,  to 
ascertain  if  this  has  occurred  the  hand  may  be  placed  on  the  joint,  or  the  limb 
adducted.  If  necessary,  repeat  the  traction  with  a  greater  degree  of  force, 
and  should  all  the  force  that  can  be  applied  short  of  giving  pain,  fail,  gentle 
rotation  of  the  limb,  first  in  one  direction  and  then  in  the  other,  can  also  be 
made  with  traction.  The  supine  position  is  the  only  one  in  which  the  muscles 
are  completely  relaxed.  The  abducted  position  removes  all  strain  from  the 
deltoid,  and  the  limb  is  placed  in  the  same  posture,  probably,  that  it  occupied 
at  the  time  of  the  accident. 

Subluxation  of  the  Lower  Jaw  treated  by  Operation. 
Professor  Annandale  (Lancet,  1887,  vol.  i.  p.  411)  points  out  that  this 
condition  is  due  to  displacement  of  the  interarticular  cartilage.  Such  dis- 
placement is  most  common  in  delicate  women,  and  is  due  either  to  inflamma- 
tory changes  of  a  simple,  gouty,  or  rheumatic  nature,  or  to  a  sudden  tearing 
or  gradual  stretching  of  the  connections  of  the  cartilage. 


244 


PKOGRESS   OF   MEDICAL  SCIENCE. 


The  author  proposes  to  relieve  the  condition  by  an  operation  similar  to  that 
which  he  has  described  for  the  relief  of  displaced  semilunar  cartilage  of  the 
knee-joint.  An  incision  slightly  curved,  about  three-quarters  of  an  inch  in 
length,  is  made  over  the  posterior  margin  of  the  external  lateral  ligament  of 
the  joint,  and  is  carried  down  to  the  capsule.  Any  small  bleeding  vessels 
having  been  secured,  the  capsule  is  divided  and  the  interarticular  cartilage  is 
seized,  drawn  into  position,  and  secured  to  the  periosteum  and  other  tissues 
at  the  outer  margin  of  the  articulation  by  a  catgut  suture.  Two  illustrated 
cases  are  given  in  women  aged  respectively  thirty-eight  and  eighteen.  In 
both  the  condition  was  perfectly  relieved. 

The  Surgical  Treatment  of  Pulmonary  Cavities. 

Mr.  Eickman  Godlee  [Lancet,  March  5,  1887,  et  seq)  has  published  two 
important  lectures  on  this  subject.  The  paper  opens  with  an  account  of  the 
history  of  this  branch  of  surgery.  Mr.  Godlee  traces  the  surgical  treatment 
of  pulmonary  cavities  back  to  the  time  of  Sir  Edward  Barry,  in  1726. 

The  following  are  the  conditions  in  which  surgical  interference  may  be  or 
has  been  attempted :  1.  Tubercular  cavities.  2.  Cavities  resulting  from  gan- 
grene of  the  lung.  3.  Cavities  resulting  from  the  bursting  into  the  lung  of 
abscesses  or  other  collections  of  irritating  matter  from  without.  4,  Bronchi- 
ectasis, from  whatever  cause  arising,  and  including  those  which  depend  upon 
the  presence  of  a  foreign  body  in  the  air  passages. 

Gangrenous  cavities  resulting  from  some  form  of  pneumonia  are  the  most 
promising  to  deal  with. 

The  author  lays  stress  upon  the  difficulty  of  dealing  with  a  non-adherent 
pleura.  "The  right  method  of  procedure  in  such  a  case,  though  I  confess  it 
is  not  a  very  easy  one,  is  carefully  to  stitch  the  lung  up  to  the  opening  which 
has  been  made  in  the  chest  walls." 

The  first  lecture  concludes  with  a  series  of  illustrative  cases  from  various 
sources  and  from  the  author's  own  practice. 

The  second  lecture  gives  a  most  valuable  account  of  the  anatomy  of  the 
bronchi,  illustrated  by  excellent  diagrams.  The  author  follows  in  the  main 
Abby's  account  of  the  parts.  The  position  of  the  principal  bronchi  with 
reference  to  the  thoracic  wall  is  given  in  detail. 

The  practical  outcome  of  the  anatomical  facts  is  expressed  as  follows:  1. 
Foreign  bodies  of  any  considerable  size  will  probably  lodge  somewhere  in  the 
main  right  bronchus  at  a  distance  not  greater  than  three  inches  from  the 
middle  line.  2.  As  regards  bronchiectases  the  smaller  peripheral  bronchi 
often  serve  as  the  starting-points  for  excavations  of  considerable  size.  3. 
Arteries  follow  with  great  regularity  the  posterior  surface  of  the  bronchi. 
They  are  of  considerable  size,  and  would  almost  certainly  be  divided  in  any 
attempt  to  open  a  main  bronchus  from  behind. 

With  regard  to  the  treatment  of  bronchiectases,  the  author  writes :  "  Our 
main  objects  in  attempting  to  open  a  bronchiectatic  cavity  are :  (1)  That  the 
secretion  from  it  may  be  prevented  from  continuing  the  mischief  in  its  passage 
over  the  bronchi,  or  as  it  is  drawn  down  into  other  parts  of  the  lungs  ;  (2)  that 
the  cough  may  be  diminished,  it  being  held  that  the  expiratory  efforts  have 
something  to  do  with  the  production  of  the  dilatation;  and  (3)  because  it  is 


SUKGEKY. 


245 


well  known  that,  though  patients  with  this  disorder  may  go  on  for  a  number 
of  years  without  succumbing  to  it,  a  very  large  number  become  comparatively 
soon  affected  with  some  form  or  other  of  blood  poisoning.  With  these  objects 
in  view,  I  should  feel  disposed  to  recommend  an  operation  if  the  physician 
were  to  express  a  strong  opinion  that  the  cavity  was  a  single  one,  or  at  least 
that  the  mischief  was  principally  caused  by  one  main  cavity,  and  also  in  those 
cases  where  it  has  arisen  from  the  irritating  presence  of  a  foreign  body  in  one 
of  the  bronchi.  In  the  latter  case  it  would  be  done  in  the  hope  of  removing 
the  foreign  body ;  in  the  former,  in  the  fear  that,  notwithstanding  the  diag- 
nosis of  a  single  cavity,  there  would  be  found  others  in  the  same  lung,  and 
not  improbably  in  the  other  lung,  which,  it  may  be,  was  supposed  to  be 
sound." 

Illustrative  cases  of  the  surgical  treatment  of  bronchiectases  are  given. 

Contusion-pneumonia. 

Dr.  A.  Koch  {Dissertation- Munich  und  Centralblatt  fur  Chirurgie,  No.  10, 
1887)  gives  what  little  is  to  be  given  of  the  history  of  this  disease,  and  adds 
the  following  case :  A  man,  aged  thirty-eight,  fell  from  a  great  height  and  re- 
ceived a  severe  contusion  of  the  left  thorax.  He  however  continued  with  his 
work  after  the  accident  and  also  on  the  second  day.  Toward  the  end  of  the 
second  day  he  began  to  feel  ill  and  experienced  a  severe  pain  in  the  chest. 
He  went  to  the  hospital,  where  he  died  three  hours  after  admission.  The 
post-mortem  showed  croupous  pneumonia  with  red  hepatization.  The  lung 
swarmed  with  the  bacilli  of  pneumonia.  The  ribs  were  not  injured.  The 
patient  was  entirely  free  from  disease  at  the  time  of  the  accident. 

The  Surgical  Treatment  of  Empyema. 

Dr.  Kasanli  (Vratch,  1866,  Nos.  13  to  18)  deals  with  this  subject  in  a 
very  exhaustive  manner.  The  paper  commences  with  an  account  of  the  his- 
tory of  the  operation.  21  cases  of  empyema  are  dealt  with.  The  subjects 
were  young  soldiers  under  care  in  a  military  hospital.  Of  the  21  patients,  10 
died ;  5  of  tuberculosis,  1  of  tetanus,  1  of  pericarditis,  1  of  pyaemia,  and  2  of 
exhaustion.  Of  those  who  recovered,  8  are  reported  as  being  perfectly  cured 
and  3  as  recovering  with  a  persisting  sinus.  The  operation  was  the  same  in 
all  cases,  and  was  as  follows.  A  rib  is  not  removed.  The  fluid — especially 
when  of  large  amount — is  removed  very  gradually  day  by  day  through  an 
aspirator.  When  the  thorax  is  nearly  empty  an  incision  is  made  under  anti- 
septic precautions,  and  a  drain  introduced  which  is  carried  into  a  vessel  con- 
taining a  solution  of  corrosive  sublimate.  A  clamp  is  applied  to  the  tube  so 
as  to  allow  of  the  slow  discharge  of  the  pus.  In  twenty-four  hours  the  wound 
is  enlarged  still  more,  free  drainage  with  a  large  open  tube  carried  out  for  the 
first  time.  The  tube  is  removed  on  an  average  on  the  thirty-fourth  day. 
Recovery  may  be  expected  by  the  forty- fourth  day. 

The  Surgical  Treatment  of  Affections  of  the  Pleura  and  Lungs. 

Dr.  Rochelt  (  Wiener  med.  Presse,  1886,  No.  32)  comes  to  these  conclu- 
sions :  In  acute  pleuritic  effusions  the  fluid  should  be  removed  at  once  by 


246 


PROGKESS   OF   MEDICAL  SCIENCE. 


aspiration.  In  cases  of  chronic  effusion  the  fluid  should  be  withdrawn  gradu- 
ally by  repeated  tappings. 

Empyema  should  be  treated  by  free  incisions.  He  gives  an  account  of  two 
cases  of  pneumothorax  in  phthisis  treated  by  operation.  One  recovered,  one 
died.  An  excellent  case  of  bronchiectasis  is  reported  that  was  cured  by  pneu- 
motomy.  The  patient  was  fifty-four  and  the  subject  of  chronic  bronchitis. 
Portions  of  ribs  were  removed  and  the  lung  cavity  opened  and  drained.  Two 
cases  of  lung  abscess  were  treated  by  incision.  Both  died  ;  while  one  case  of 
gangrene,  treated  by  the  same  measure,  ended  in  recovery. 

Dr.  Ribbing  {Eira,  1886,  No.  16,  Sweden)  deals  with  sixteen  cases  of 
empyema,  all  treated  by  operation.  Strict  antisepsis  was  employed  and  free 
drainage.  In  no  case  did  death  result.  In  children  the  author  considers  that 
simple  incision  is  sufficient.  In  adults,  when  relapse  occurred,  portions  of 
ribs  were  resected.  Washing  out  of  the  cavity  is  not  ordered  unless  the  pus 
be  putrid.    In  all  cases  the  evacuation  of  the  matter  should  be  slow. 

The  Diagnosis  of  Stricture  of  the  (Esophagus. 

Professor  Ogston  [Medical  Chronicle,  January,  1887,  p.  278)  points  out 
the  difficulties  in  the  diagnosis.  There  may  be  dysphagia — depending  upon 
dyspepsia,  bronchitis,  or  post-diphtheritic  paralysis — and  yet  no  stricture. 
Stricture  at  the  lower  end  of  the  gullet  is  most  common  in  patients  past 
middle  life,  and  is  due  to  cancer.  In  such  cases  the  author  lays  stress  upon 
the  painful  distention  of  the  gullet  after  swallowing,  felt  in  the  centre  of  the 
thorax  and  the  accompanying  breathlessness  and  sense  of  distress. 

Strictures  in  the  upper  part  of  the  oesophagus  usually  occur  in  younger 
subjects,  and  depend  upon  cicatrix,  diphtheria,  or  syphilis.  In  such  cases  the 
pharyngeal  distention  on  swallowing  can  be  made  out  on  the  left  side  of  the 
neck. 

In  making  a  diagnosis  Professor  Ogston  lays  great  stress  upon  the  time 
occupied  by  the  act  of  swallowing.  In  healthy  subjects  the  passage  of  the 
food  along  the  gullet  occupies  from  two  and  a  half  to  eight  seconds.  In  cases 
of  stricture  it  occupies  from  fourteen  to  eighteen  seconds. 

The  starting  of  the  bolus  is  indicated  by  the  movement  of  the  pomum 
Adami.  "  If  the  ear  be  placed  behind  the  left  thorax,  tlr:ee  inches  below  the 
angle  of  the  scapula,  the  moment  of  entrance  into  the  stomach  can  nearly 
always  be  told  by  a  distinct  amphoric  gurgle  or  amphoric  rushing  sound.  By 
noting  these  two  points  the  time  involved  in  the  act  of  swallowing  is  indicated." 

Lipoma  of  the  Mesentery. 

M.  Terillon  {Bull,  et  Mem.  de  la  Soc.  de  Chir.,  t.  xii.  p.  23)  reports  the 
case  of  a  man  aged  thirty-five,  upon  whom  laparotomy  was  performed  for  the 
removal  of  a  large  lipoma.  The  mass  had  grown  between  the  layers  of  the 
mesentery,  and  weighed  fifty-seven  pounds.  The  patient  died  of  enteritis 
(followed  by  peritonitis)  on  the  thirty-second  day  after  the  operation. 

M.  Terillon  gives  details  of  14  other  cases  of  lipoma  of  the  mesentery.  7 
were  discovered  on  post-mortem  examination,  and  7  were  removed  by  opera- 
tion. Of  the  latter,  only  2  recovered.  Death  was  in  each  case  due  to  either 
shock  or  peritonitis.    Mesenteric  lipomata  occur  in  adults,  and  always  grow 


SURGERY. 


247 


between  the  layers  of  the  mesentery.  The  intestines  lie  in  front  of  them,  or 
to  one  side.  Ascites  is  rare,  and  adhesions  are  occasionally  met  with.  A 
correct  diagnosis  is  not  usually  made,  the  affection  being  mistaken  for  cystic 
tumors  in  most  instances.  Pathologically,  the  growths  belong  to  the  myxo- 
lipomata. 

The  Etiology  of  Peritonitis. 

Dr.  Grawitz  (Charite- Annalen,  XI.  Jarhgang,  p.  779)  has  published  a 
very  valuable  paper  upon  this  subject.  It  is  founded  upon  an  extensive  series 
of  experiments  made  upon  the  lower  animals. 

Into  the  elaborate  details  of  the  research  it  is  impossible  to  enter.  The 
more  important  conclusions  are  these:  Schizomycetes  or  Staphylococcus 
aureus  injected  into  the  peritoneal  cavity  will  not  of  themselves  produce  peri- 
tonitis if  the  injecting  medium  be  non-irritating.  In  the  production  of  sup- 
purative peritonitis  two  conditions  are  necessary  in  the  majority  of  cases:  1. 
The  introduction  of  pus-producing  microorganisms  ;  and,  2.  The  existence  of 
some  local  disturbance.  The  latter  condition  is  afforded  when  the  intestinal 
tube  is  gorged  with  much  stagnant  matter  and  when  the  serous  membrane 
has  been  denuded  of  its  epithelial  covering. 

The  subject  of  peritonitis  from  cold  is  discussed,  and  Dr.  Grawitz  concludes 
that  cold  alone  cannot  become  a  cause  of  peritonitis,  nor  does  he  consider  it 
an  important  local  factor  when  the  other  possible  causes  of  peritonitis  are 
present. 

The  paper  concludes  with  a  consideration  of  the  peritonitis  that  often 
attends  stenosis  of  the  bowel  and  strangulated  hernia.  In  both  circumstances 
local  damage  to  the  serous  membrane  plays  a  very  conspicuous  part. 

The  Treatment  of  Hemorrhoids  by  Excision. 

Mr.  Whitehead  (British  Medical  Journal,  vol.  i.  p.  449,  1887)  gives  an 
account  of  no  less  than  300  consecutive  cases  treated  by  means  of  the  opera- 
tion that  now  goes  by  his  name. 

The  treatment  by  ligature  is  very  unsatisfactory  and  a  relapse  is  quite  com- 
mon. The  treatment  by  the  clamp  and  cautery  is  still  more  unsatisfactory. 
Its  immediate  risks  are  greater  and  its  failures  by  recurrence  more  numerous. 

The  present  operation  has  been  performed  upon  over  300  patients  without 
a  death,  a  single  instance  of  secondary  hemorrhage,  or  one  case  where  any 
complication  such  as  ulceration,  abscess,  stricture,  or  incontinence  of  feces, 
has  occurred. 

The  following  are  the  details  of  the  operation :  The  patient  is  anaesthetized 
and  placed  in  the  lithotomy  position.  The  sphincters  are  well  paralyzed  by 
stretching.  By  the  use  of  screws  and  dissecting  forceps  the  mucous  membrane 
is  divided  at  its  junction  with  the  skin  round  the  entire  circumference  of  the 
bowel,  every  irregularity  of  the  skin  being  carefully  followed.  The  external 
and  the  commencement  of  the  internal  sphincters  are  then  exposed  by  a  rapid 
dissection,  and  the  mucous  membrane  and  attached  hemorrhoids,  thus  sepa- 
rated from  the  submucous  bed  on  which  they  rested,  are  pulled  bodily  down, 
any  undivided  points  of  resistance  being  snipped  across  and  the  piles  brought 
below  the  margin  of  the  skin.    The  mucous  membrane  above  the  piles  is  now 


248 


PKOGKESS   OF   MEDICAL  SCIENCE. 


divided  transversely  in  successive  stages,  and  the  free  margin  of  the  severed 
membrane  alone  is  attached,  as  soon  as  divided,  to  the  free  edge  of  the  skin 
below  by  sutures.  Bleeding  vessels  are  secured  by  twisting.  A  complete  ring 
of  pile-bearing  mucous  membrane  is  thus  removed.  No  skilled  assistance  is 
required.  The  wound  is  dressed  with  iodoform.  The  sutures  are  of  carbo- 
lized  silk  and  are  not  removed.  Castor-oil  is  given  on  the  morning  of  the 
fourth  day.  The  patient  can  resume  work  within  a  fortnight.  The  amount 
of  pain  after  the  operation  is  trifling,  and  retention  of  urine  is  uncommon. 

Hernia  of  the  Cmcum. 

Mr.  Frederick  Treves  {British  Medical  Journal,  1887,  vol.  i.  p.  382) 
commences  a  monograph  upon  this  subject  by  an  account  of  the  history  of 
the  hernia  as  displayed  in  surgical  literature.  In  one  of  the  earlier  recorded 
cases  (1732)  the  caecum  was  exposed  and  entirely  excised,  the  patient  making 
a  good  recovery.  Mr.  Treves  draws  attention  to  the  fact  that  the  text-books 
describe  the  caecal  hernia  as  being  without  a  sac.  An  account  is  given  of  the 
various  reported  cases  upon  which  this  statement  is  founded,  and  it  is  shown 
that  in  the  more  conspicuous  instances  the  evidence  is  unsatisfactory. 

Two  cases  are  given.  The  first  was  met  with  in  a  man  aged  forty-one.  The 
rupture  was  inguinal,  the  sac  was  double,  and  of  enormous  size.  The  sac  was 
cut  away,  the  caecum  exposed  and  reduced.    A  complete  cure  resulted. 

The  second  case  was  in  a  woman  aged  fifty-six,  and  occupied  the  femoral 
region.    The  appendix  could  be  distinctly  felt.    The  hernia  was  reducible. 

The  author  proceeds  to  examine  15  recent  cases  (8  from  recent  records,  9 
from  metropolitan  museums).  It  appears  that  the  hernia  is  much  more 
common  in  the  inguinal  than  the  femoral  region,  and  is  more  common  in  males 
than  in  females.  There  is,  in  nearly  every  instance,  a  perfect  sac.  In  a  few 
examples  it  was  incomplete ;  in  no  case  was  it  absent.  The  caput  coli  may 
be  protruded  alone,  or  in  the  hernia  coils  of  ileum  and  omentum  may  be 
found.    The  rupture  tends  soon  to  become  irreducible. 

Mr.  G.  A.  Wright  {Ibid.,  p.  507)  gives  an  account  of  seven  cases  of  caecal 
hernia  in  children.  The  patients  were  between  the  ages  of  three  months  and 
seven  years.  They  were  all  males,  and  the  rupture  in  each  instance  inguinal. 
In  all  the  cases  operated  upon  there  was  a  perfect  and  well-defined  sac.  The 
sac  may  be  funicular,  or  be  formed  from  the  open  tunica  vaginalis. 

The  paper  serves  to  modify  Mr.  Treves's  statement  that  "the  hernia  of  the 
caecum  is  practically  limited  to  adults." 

Parotitis  in  Association  with  Abdominal  Disease. 

Mr.  Stephen  Paget  [British  Medical  Journal,  March  19,  1887)  has,  with 
great  diligence,  collected  no  less  than  101  cases  of  parotitis  consequent  upon 
injury  or  disease  of  the  abdomen  or  pelvis;  of  this  number,  10  were  due  to 
injury  or  disease  of  the  urinary  tract;  18  were  due  to  injury  or  disease  of  the 
alimentary  canal,  and  23  were  due  to  injury  or  disease  of  the  abdominal, 
the  peritoneum,  or  the  pelvic  cellular  tissue.  The  remaining  50  were  due  to 
injury  or  disease,  or  temporary  derangement  of  the  generative  organs.  Under 
the  latter  term  are  included  slight  blows  on  the  testis,  the  introduction  of  a 
pessary,  menstruation,  and  pregnancy. 


SURGERY. 


249 


This  form  of  parotitis  appears  to  be  non-pysemic,  to  have  no  definite  incu- 
bation stage,  and  to  end  very  often  in  suppuration.  Mr.  Paget  considers  that 
the  sequence  of  disease  is  due  to  influences  acting  through  the  nervous  system. 

The  Treatment  of  Ectopion  Vesicae. 

Dr.  Zesas  ( Centralblatt  fur  Chirurgie,  No.  8,  1887)  advocates  Sonnenburg's 
operation,  which  consists  in  removing  the  defective  bladder  and  turning  the 
ureters  into  the  penis.  The  object  of  the  present  paper  is  to  describe  a  special 
receptacle  devised  by  the  author,  to  be  worn  after  Sonnenburg's  operation. 
It  consists  of  two  parts — a  rounded  concave  shield  to  cover  the  abdominal 
wound,  and  a  scrotal  funnel,  which  receives  the  scrotal  tissues  and  the  rudi- 
mentary penis,  and  leads  into  a  tube  emptying  itself  into  an  ordinary  urinal. 
The  shield  and  funnel  are  made  of  silver,  and  the  points  of  contact  are 
covered  with  an  India-rubber  tube,  as  on  the  edge  of  an  ether  inhaler.  A 
case  is  described  where  the  appliance  was  used.  The  patient  was  always  kept 
perfectly  dry.    Excellent  illustrations  accompany  the  paper. 

Suprapubic  Lithotomy. 

Sir  William  MacCormac  (British  Medical  Journal,  1887,  vol.  i.  p.  551) 
contributes  another  valuable  paper  upon  this  subject.  The  article  commences 
with  an  account  of  the  history  of  the  operation.  The  modern  method  is 
described  as  follows :  Strict  antiseptic  precautions  are  adopted  throughout. 
The  lectum  is  distended  by  an  India-rubber  bag,  of  elongated  sausage-form. 
10  to  12  ounces  are  injected.  The  bladder  is  emptied,  is  washed  out,  and  then 
moderately  distended  with  boric  solution  (6,  8,  or  10  ounces).  The  bladder 
will  then  be  readily  felt  above  the  pubes.  The  incision  is  median,  is  close  to 
the  pubes,  and  from  2  to  4  inches  in  length.  The  tissues  are  divided  layer  by 
layer,  until  the  bladder  is  distinctly  exposed.  After  the  viscus  has  been 
secured  by  two  loops  of  thread  passed  through  the  muscular  coat  at  the  upper 
exposed  part,  the  cavity  is  opened.  The  stone  is  then  removed.  In  young 
persons  with  healthy  urine  the  wound  in  the  bladder  may  be  closed  by  sutures, 
in  other  cases  the  wound  may  be  left  open  with  or  without  drainage. 

The  author  gives  an  account  of  a  series  of  experiments  performed  to  ascer- 
tain the  effect  of  distention  of  the  bladder  and  rectum  upon  the  position  of 
the  peritoneal  reflection.  When  the  bladder  alone  is  distended,  the  peritoneal 
reflection  is  somewhat  but  not  sufficiently  raised,  the  bladder  being  chiefly 
distended  backward.  Distention  of  the  rectum  alone  appears  to  produce  no 
palpable  effect  on  the  vesical  fold ;  and  to  obtain  the  maximum  result,  dis- 
tention of  both  bladder  and  rectum  seems  necessary.  The  dilatation  of  the 
rectal  bag  pushes  the  moderately  distended  bladder  forward  and  upward 
against  the  parietes. 

The  following  indications  for  the  operation  are  given :  A  large  stone  in  a 
contracted  bladder,  a  stone  projecting  into  the  urethra,  encapsulated  or  very 
hard  calculi,  cases  of  numerous  stones,  certain  foreign  bodies,  ricketty 
deformity  of  the  pelvis,  and  ankylosis  of  the  hip-joint.  Some  add  hypertro- 
phy of  the  prostate,  stricture,  and  irritable  bladder. 

The  mortality  after  the  suprapubic  method  is  from  22  to  30  per  cent.  The 


250 


PROGKESS   OF   MEDICAL  SCIENCE. 


commoner  causes  of  death  are  (in  order)  peritonitis,  pericystitis,  pyelone- 
phritis, collapse. 

In  26  cases  of  suture  of  the  bladder  wound  primary  union  was  obtained  in 
10  cases  only.   

Lithotomy. 

Dr.  Rosenthal  ( Vratch,  1886,  Nos.  25-32)  gives  the  following  valuable 
statistical  account.  He  deals  with  400  cases  of  lateral  lithotomy.  47  per  cent, 
of  the  cases  concerned  patients  under  seven  years  of  age,  and  66  per  cent, 
patients  between  seven  and  thirteen  years.  Out  of  the  400  only  40  died,  a 
mortality  of  10  per  cent.  In  6  of  the  fatal  cases,  death  was  not  directly  due 
to  the  operation,  and  the  omission  of  these  raises  the  mortality  to  8.5  per  cent. 
The  mortality  increased  steadily  according  to  age,  being  3.5  per  cent,  in 
patients  under  five  years,  and  36.8  per  cent,  in  patients  between  the  ages  of 
thirty  and  sixty-six. 

The  mortality  in  7628  recorded  cases  of  lateral  lithotomy  collected  by  the 
author  is  12.08  per  cent.  The  mortality  of  the  suprapubic  operation,  on  the 
other  hand,  stands  at  22.1  per  cent. 

Out  of  the  40  cases  of  death,  17  died  of  pyonephritis.  The  rectum  was 
wounded  6  times  in  the  400  operations. 

The  time  occupied  in  healing  averaged  18.6  days  in  patients  under  ten 
years,  and  27.2  days  in  patients  above  that  age. 

The  character  of  the  calculus  was  determined  as  follows :  urates,  70  per 
cent. ;  oxalates,  11  per  cent.  ;  mixed  (phosphates  predominating),  19  per  cent. 

Primary  Sarcoma  of  the  Bladder. 

Dr.  Chiari  (Prager  med.  Wochenschrift,  1886,  No.  50)  reports  a  case  of  this 
very  rare  affection.  He  states  that  only  seven  cases  have  so  far  been  reported. 
The  patient  was  a  boy  aged  five;  the  first  symptoms  were  those  of  retention,, 
followed  by  the  manifestations  of  chronic  cystitis.  No  blood  appeared  in  the 
urine  until  a  catheter  was  used.  The  tumor  could  be  felt  through  the  abdomi- 
nal parietes.  The  tumor  sprang  from  the  submucosa  about  the  trigone.  The 
prostate  and  seminal  vesicles  were  invaded.  A  solitary  gland  was  found 
enlarged.  There  were  no  other  metastases.  The  growth  proved  to  be  a  pure 
spindle-celled  sarcoma. 

The  Function  of  the  Prostate. 

Dr.  Furbring-er  {Berliner  Jclin.  Wochenschrift,  1886,  No.  29)  states  that  the 
prostatic  fluid  is  thin  and  acid,  is  rich  in  albumen,  contains  lecithin  but  no 
fat.  The  author  believes  that  the  fluid  has  other  functions  than  that  of  a 
mere  lubricating  medium.  He  states  that  it  acts  as  a  vitalizer  of  the  seminal 
fluid,  and  is  of  essential  importance  in  the  act  of  generation.  In  semen 
unmixed  with  the  prostatic  secretion  the  spermatozoa  are  found  to  be  stiff  and 
still ;  on  the  addition,  however,  of  that  fluid,  they  become  at  once  subtle  and 
active.  The  addition  of  an  excess  of  prostatic  secretion  causes  the  seminal 
particles  to  become  once  more  indolent. 

These  statements  are  founded  upon  observations  made  on  animals,  and  on 
certain  pathological  experiments  carried  out  upon  the  human  subject. 


SURGERY. 


251 


Renal  Surgery. 

T.  F.  Chavasse  [Lancet,  1887,  p.  403)  gives  an  account  of  three  cases 
that  proved  fatal  after  operation.  In  his  comments  upon  these  cases  the 
author  deduced  the  following  conclusions :  To  obtain  the  greatest  possible 
benefit  from  operative  measures  renal  calculi  must  be  sought  for  and  removed 
before  destruction  and  consequent  abscess  have  resulted.  The  signs  and 
symptoms  most  to  be  relied  upon  for  the  diagnosis  of  renal  calculus,  where 
no  tumor  exists,  the  patient  being  otherwise  healthy,  are  the  following:  1. 
The  presence  of  blood  in  the  urine,  especially  after  erection.  2.  Unilateral 
pain  passing  down  the  ureter  toward  the  testis.  3.  Pain  on  deep  pressure  in 
loin  between  the  last  rib  and  the  iliac  rest  and  just  external  to  the  erector 
spinse  muscle.  4.  The  presence  of  uric  acid  and  oxalate  crystals  in  the  urine. 
In  suppurative  lesions  of  the  kidney  nephrotomy  and  drainage  should  be  the 
first  measure  in  treatment. 

In  one  case  the  author  passed  an  exploring  needle  twelve  times  into  the 
substance  of  the  kidney,  but  failed  to  reveal  a  calculus  and  a  fair  sized  abscess 
that  were  ultimately  discovered  post-mortem. 

Speaking  generally,  there  is  no  doubt  that  the  lumbar  incision  is  safer  than 
the  abdominal.  The  author  advises  nephrectomy  under  these  conditions: 
After  nephrotomy  and  drainage  have  failed  in  cases  of  suppurative  lesions 
depending  upon  a  local  irritant,  in  hydronephrosis,  and  in  traumatic  rupture 
of  the  kidney.  It  is  justifiable  also  in  cases  of  painful  floating  kidney  when 
attempts  to  free  the  organ  have  failed,  and  in  troublesome  renal  or  ureteral 
fistula.  Nephrectomy  is  contraindicated  in  tubercular  disease,  carcinoma 
in  adults,  and  sarcoma  in  children. 

The  following  articles  are  worthy  of  note : 

"Abscess  of  the  Brain  Eesulting  from  Ear  Disease,"  by  Dr.  Thomas  Barr 
{Brit.  Med.  Journ.,  April  2,  1887). 

"Pianists'  Cramp,"  by  Dr.  Warrington  Howard  [Brit.  Med.  Journ.,  March 
26,  1887). 

"Case  of  Mollities  Ossium  in  a  Male,"  by  Mr.  Barwise  [Brit.  Med.  Journ., 
April  9,  1887). 

"Laparotomy  in  Intestinal  Obstruction,"  by  Dr.  Kumwell  {Deutsche  med. 
Wochenschrift,  No.  12).  Four  cases  :  two  of  volvulus,  one  of  mesenteric  hole, 
one  of  solitary  band.    Laparotomy  in  each  instance,  with  only  one  recovery. 

"The  Theory  of  Gut  Strangulation,"  by  Dr.  Beeby  {Centralblatt  fur  Chirurgie, 
No.  14,  1887).  An  examination  of  KeicheFs  view,  with  a  new  and  elaborate 
theory  of  the  author's. 

" Chondromyosarcoma  of  Kidney,"  by  Dr.  Hoiaholt  [Virchow's  Archiv, 
Bd.  civ.  p.  118).  Male,  aged  eighteen ;  left  kidney.  Died  of  marasmus. 
Tumor  composed  of  round-celled  sarcoma  mixed  with  muscle  fibre  and 
nodules  of  cartilage. 

"Seven  Consecutive  Cases  of  Charbon  Treated  Successfully  by  Excision," 
by  Thomas  Bryant  {Lancet,  1887,  vol.  i.  pp.  367  and  416). 

"Case  of  Trephining  over  the  Left  Branchial  Centre  for  Paralysis  of  the 
Right  Arm  due  to  a  blow  a  week  previously.  Cure,"  by  A.  W.  Robson 
{Lancet,  1887,  vol.  i.  p.  464). 


252 


PROGRESS   OF    MEDICAL  SCIENCE. 


"On  Sounding  the  Frontal  Sinus,"  by  Dr.  Jurasz  {Berliner  hlin.  Wochen- 
schrift,  No.  3,  1887).  The  probe  is  introduced  from  the  nose.  The  utility  of 
the  procedure  is  not  evident. 

"Vesical  Fistula  after  a  Radical  Operation  for  Hernia,"  by  Dr.  Feilchen- 
feld  {Berliner  hlin.  Woehenschrift,  No.  3,  1887).  Male,  aged  fifty-one;  scrotal 
hernia.  Removal  of  sac  with  ligature  of  neck.  Urinary  fistula  formed  at 
wound,  which  closed  after  many  weeks.  The  author  supposes  that  a  vesical 
diverticulum  must  have  been  engaged  in  the  ring. 

"The  Classification  of  Tumors  of  the  Testicle,"  by  Drs.  Monod  and  Arthaud 
{Revue  de  Chirurgie,  March  10,  1837). 

"  Malformations  of  the  Anus,"  by  Dr.  Jeannel  {Revue  de  Chirurgie,  March 
and  April,  1887). 


In  America. 


Removal  of  a  Large  Sarcoma,  causing  Hemianopsia,  from  the 
Occipital  Lobe. 

Drs.  W.  R.  Birdsall  and  Robert  F.  Weir  ( The  Medical  Neivs,  April  16, 
1887)  make  a  most  important  contribution  to  brain  surgery;  among  other 
points  demonstrating  that  hemorrhage  must  be  primarily  arrested  in  opera- 
tions involving  the  brain  structure  by  reliable  methods,  such  as  the  ligature, 
torsion,  or  prolonged  forcipressure,  and  not  by  the  tampon. 

A  man,  set.  forty-two,  in  August,  1885,  suddenly  noticed  unsteadiness  of 
gait,  succeeded  by  a  violent  attack  of  vomiting.  Diplopia  for  distance 
soon  appeared,  with  increasing  muscular  incoordination;  numb  sensations 
of  the  right  arm,  leg,  and  shoulder;  but  no  disorder  of  sensation  of  the  face. 
All  these  symptoms  were  intermittent.  Occasional  moderate  frontal  headache 
was  experienced.  No  vertigo  was  noticed  at  first,  and  no  other  sensory, 
motor,  or  visceral  symptoms  appeared.  Hemianopsia,  was  detected,  with 
incipient  neuro-retinitis.  The  diagnosis  was,  "tumor  of  mesial  aspect  of  right 
occipital  lobe,  involving  primarily  the  cuneus,  extending  downward  toward 
the  tentorium  cerebelli,  and  perhaps  also  upward  toward  the  paracentral 
lobule  (leg  centre)."  Slight  improvement  in  gait,  under  the  use  of  iodide  of 
potassium,  was  observed  until  as  late  as  July,  1886 ;  but  in  September  the 
muscular  incoordination  and  occasional  drowsiness  rapidly  increased. 

Examination  now  showed  the  left  lateral  hemianopsia  still  present;  the 
neuritis  well  advanced,  although  more  marked  in  the  left  eye;  irides  active, 
both  to  light  and  accommodation — the  left  pupil  larger  than  the  right ;  no 
diplopia,  no  "ocular  paresis;"  the  special  senses  were  normal,  and  there  was 
neither  anaesthesia,  analgesia,  disturbance  of  the  temperature  sense,  paresis, 
nor  tremor  of  the  muscles;  and  the  motions  were  "clumsy,"  rather  than 
ataxic — "uncertainty  of  control"  seemed  the  best  term  for  it;  and  the  dis- 
turbance of  equilibrium  increased  in  a  most  irregular  manner. 

On  March  9, 1887,  Dr.  Weir  operated  antiseptically.  An  oval  opening,  two 
and  three-quarters  by  two  and  one-quarter  inches,  was  made  through  the  bone 
by  means  of  a  trephine  and  the  rongeur.    The  non-pulsatile  dura  mater  was 


SURGERY. 


253 


opened  for  two-thirds  of  the  extent  of  the  bone  wound,  and  the  tumor,  of  a 
purplish-red  color,  presented  at  once,  covered  by  a  thin  cellular  layer  con- 
taining large  ramifying  veins.  By  means  of  a  director  and  spoon-handle,  a 
thin  layer  of  brain  substance  was  loosened  from  its  outer  side,  and  by  a  con- 
tinuance of  these  proceedings  the  growth  was  readily  separated  at  the  sides; 
but  even  after  further  free  removal  of  bone  tissue,  the  outlying  edges  and 
base  of  the  growth  could  not  be  reached  until  it  was  incised  and  its  softened 
interior  squeezed  out.  After  this,  separation  was  readily  effected  by  the 
finger-nail  until  the  base  was  reached,  when  the  growth  was  nearly  torn  in 
half,  its  outer  portion  lifted  out,  separated  from  the  falx,  and  the  whole  mass 
withdrawn.  Considerable  venous  oozing  occurred,  but  was  readily  arrested 
by  sponge  pressure.  Two  bleeding  points  were  seen :  one  venous,  in  the  region 
of  the  straight  sinus;  and  the  other  arterial,  possibly  a  terminal  branch  of  the 
posterior  cerebral  artery.  Moderately  firm  packing  with  iodoform  gauze  to 
check  bleeding,  partial  suture  of  the  dura  mater  and  scalp,  with  a  careful 
antiseptic  dressing,  completed  the  operation.  Some  failure  of  the  pulse  was 
observed  when  the  growth  was  being  lifted  out,  probably  due  to  loss  of  blood 
— in  all,  computed  to  be  from  f^x  to  f^xij — but  hypodermatics  of  whiskey 
relieved  this  condition. 

After  the  rapid  recovery  from  the  anaesthetic,  slight  divergent  squint  of  the 
left  eye  was  noted ;  the  pulse  was  132,  regular,  and  of  good  volume.  Ene- 
mata  of  milk  punch  were  ordered  every  two  hours.  Two  hours  after  operation 
the  pulse  was  120,  weak,  and  there  was  much  blood-staining  of  the  dressings. 

At  10  P.  m.  the  patient  was  very  restless,  with  an  extremely  weak  pulse 
and  steady  bleeding  was  evidently  going  on.  Two  quarts  of  salt  solution,  as 
modified  by  Landerer,  were  slowly  injected  into  the  median  basilic  vein  with 
immediate  improvement  in  the  pulse  and  consciousness.  Slight  paralysis  of 
the  ocular  branch  of  the  seventh  nerve  was  now  detected,  in  addition  to  the 
already  noted  divergent  squint  on  the  left  side.  Hemorrhage  being  evidently 
the  cause  of  the  unfavorable  symptoms,  the  dressings  were  removed,  but  such 
free  bleeding  occurred  as  to  forbid  anything  more  than  the  application  of  an 
additional  iodoform  gauze  tampon,  and  a  second  transfusion  was  made ;  but, 
despite  everything,  death  occurred  at  2  A.  M. 

Dr.  Weir  regrets  that  forcipressure  forceps,  allowed  to  remain  for  from 
twenty-four  to  forty-eight  hours,  with  elevation  of  head,  had  not  been  re- 
sorted to  at  the  outset.  The  advisability  and  dangers  of  free  bone  openings 
are  discussed,  bone-grafting  is  advocated,  either  by  dusting  the  finely  minced 
bone  over  the  dura  mater,  or  by  replacement  of  the  trephine  disks. 

This  case  makes  the  eighth  operated  on  for  brain  tumor.  In  five  instances 
the  growth  was  found  and  removed  ;  in  one,  partial  removal  was  effected  ;  and 
in  the  remaining  two,  no  tumor  was  found,  although  in  one  case  the  post- 
mortem, two  and  a  half  months  later,  revealed  a  growth  pressing  upon  the 
cerebellum  and  spinal  cord. 

The  growth  weighed  5£  ounces,  and  measured  3^  inches  by  2 J  by  21  inches 
thick,  the  greater  circumference  measuring  8£  inches. 

Pleurotomy  by  Resection  of  the  Ribs  for  Empyema. 
Dr.  W.  H.  Strickler  {The  Medical  News,  May  7,  1887)  describes  the  fol- 
lowing operation :  Across  the  sixth  rib  in  the  axillary  region  a  vertical  cut  of 


254 


PROGRESS  OF   MEDICAL  SCIENCE. 


three  inches  is  made  with  its  centre  over  the  rib.  A  transverse  cut  of  one 
inch  crosses  the  primary  one  at  its  centre.  The  sixth  rib  is  bared,  partially 
divided  at  two  points  by  a  Hey's  saw,  and  finally  severed  by  bone  forceps. 
The  pleura  now  being  opened  the  chest  is  explored  by  the  finger  to  ascertain 
the  position  of  the  diaphragm,  when  a  section  of  the  seventh  and  of  the  fifth 
ribs  is  removed— about  one  inch  of  these,  while  the  exsected  portion  of  the 
sixth  rib  measures  one  and  a  half  inches ;  this  is  to  secure  space  between  the 
extremities  of  the  segments  of  this  rib,  when  the  cut  ends  of  the  fifth  and 
seventh  ribs  are  driven  together  by  atmospheric  pressure.  All  bone  sections 
having  been  completed,  the  pleural  cavity  is  carefully  explored,  by  the  whole 
hand,  except  the  thumb,  all  fibrinous  masses  are  carefully  removed,  any  bands 
likely  to  prevent  expansion  of  the  lung  ruptured,  and  the  cavity  thoroughly 
irrigated  with  large  quantities  of  hot  water.  All  but  the  centre  of  the  wound 
is  sutured,  and  gauze  and  oakum  applied  over  all.  After  the  first  week  a  tube 
is  used  to  keep  the  wound  patent,  which  is  gradually  reduced  in  size.  From 
the  outset,  daily  flushings  with  hot  water  are  used.  Five  cases  are  reported, 
which  have  done  well.    The  operation  is  a  modification  of  one  in  general  use. 

Pistolshot  Wound  of  the  Abdomen;  Laparotomy;  Nephrectomy; 

Autopsy. 

Dr.  W.  W.  Keen  {The  Medical  News,  May  14,  1887)  gives  the  details  of  a 
most  interesting  case,  which  should  be  carefully  studied  by  every  surgeon, 
illustrating,  as  it  does,  many  points  which  are  both  new  and  of  practical 
importance  in  this  latest  field  of  operative  surgery.  The  title  contains  nearly 
all  the  essential  points,  and  since  nothing  short  of  an  almost  complete  repro- 
duction of  the  paper  could  do  it  justice,  we  shall  merely  add  what  seems  to 
be  the  apparent  cause  of  the  fatal  termination  of  a  case  which  bade  fair  to 
recover,  and  one  or  two  minor  points  worthy  of  comment.  Generalized,  non- 
suppurative peritonitis  was  found  post-mortem,  and  a  gangrenous  portion  of 
bowel  opposite  to  the  ball  wound  of  the  intestine,  in  the  centre  of  the  dead 
portion  two  perforations  existing  with  pus  in  the  lumen  of  the  bowel.  This 
was  probably  the  cause  of  the  peritonitis,  and  Dr.  Keen  thinks  resulted  from 
contusion  of  the  mesentery  not  detectable  at  the  operation,  but  causing  throm- 
bosis of  the  arterial  supply  to  the  portion  of  bowel-wall  which  necrosed.  An 
extensive  intermesenteric  layer  of  blood  effused  before,  and  found  at  the  oper- 
ation, had  also  broken  down  and  looked  purulent,  but  did  not  communicate 
with  the  peritoneal  cavity.  At  the  post-mortem  examination  the  right  kidney 
was  found  to  have  undergone  marked  compensatory  enlargement,  which  the 
clinical  history  indicated  must  have  taken  place,  since  the  urine,  while  scanty 
at  first,  gradually  increased  in  three  days  from  ^iij  of  albuminous  fluid  to  ^xl 
of  normal  secretion. 

Splenectomy  for  Wandering  Spleen. 

Dr.  W.  H.  Myeps  reports  {Journal  of  the  American  Medical  Association,  April 
2,  1887)  a  successful  case,  the  operation  being  demanded  for  the  relief  of 
septic  symptoms  induced  by  abscess,  resulting  apparently  from  the  pressure  of 
an  enlarged  and  dislocated  spleen.  The  suppuration  was  unquestionably 
favored  by  the  post-partum  state,  the  patient  having  been  delivered  about  three 


SURGERY. 


255 


weeks  previously,  although  the  splenic  hypertrophy  had  existed  to  a  marked 
degree  for  over  one  year.  The  perisplenic  abscess  had  opened  externally 
before  operation  by  three  orifices.  Strict  antisepsis  was  attempted  and  secured. 
The  pedicle  was  transfixed  by  a  double  ligature,  tied  in  halves,  and  dropped 
into  the  cavity,  and  a  glass  drainage  tube  inserted.  The  tumor  weighed  seven 
pounds.  Recovery  was  prompt,  the  patient  going  home  on  the  twenty-first  day. 

Aneurisms  Treated  by  the  Introduction  of  Catgut  or  of  Wire, 
with  Electricity. 

In  this  most  interesting  paper  ( The  Medical  News,  April  9, 1887)  Dr.  Eobert 
Abbe  reviews  the  histories  of  those  cases  treated  by  wire  alone,  and  then  relates 
an  instance  in  his  own  practice,  where  the  introduction  of  one  hundred  feet  of 
aseptic  No.  1  catgut  into  the  cavity  of  a  large  dissecting  aneurism  of  the  right 
subclavian  artery  was  of  temporary  benefit.  Increase  in  size  occurring  after  a 
few  days,  one  hundred  and  fifty  feet  of  fine  sterilized  steel  wire  were  introduced 
through  an  insulated  aspirator  needle,  the  positive  pole  of  a  galvano-faradic 
battery  was  attached  to  the  extremity  of  the  wire,  while  a  copper  plate — 12 
inches  by  12  inches — covered  with  wet  cotton,  placed  over  the  back,  was  con- 
nected with  the  negative  pole.  A  current  of  fifty  milliamperes  was  at  first 
used,  finally  a  very  much  stronger  current,  the  current  being  reversed  during 
the  latter  part  of  the  operation,  which  occupied  one  hour.  For  twenty- 
four  hours  decided  hardening  of  the  tumor  was  noted,  then  it  rapidly  in- 
creased, death  resulting  on  the  second  evening  from  rupture  into  the  trachea. 

The  writer  reviews  the  results  of  this,  and  similar  treatment,  in  the  prac- 
tice of  others,  concludes  that,  as  it  has  only  been  tried  in  desperate  cases,  we 
are  not  able  to  decide  what  value  inheres  to  the  practice,  and  thinks  that,  as 
it  does  no  harm,  it  should  be  still  tried — all  the  more,  as  the  post-mortem  results 
show  that  in  many  cases  large  quantities  of  firm,  laminated  clot  have  been 
formed,  while  "  the  subsequent  much-desired  inflammation  of  the  sac  was 
easily  kept  under  control  by  ice-bags  in  every  case."  Two  cures  have  resulted 
from  the  introduction  of  wire,  while  electrolysis  alone  has  occasionally  suc- 
ceeded. In  reality,  Dr.  Abbe  has  combined  both  methods — i.  e.,  introducing 
a  tangled  mass  of  easily  compressible  wire  reaching  every  portion  of  the  sac, 
and  then  inducing  deposition  of  clot  upon  it  by  electrolysis  ;  in  addition, 
inflammation  of  the  sac,  which  Cinicelli  contends  is  essential  to  the  success 
of  his  method,  is  induced. 

A  Case  of  Innominate  Aneurism  treated  by  Simultaneous  Distal 
Ligation  of  the  Eight  Carotid  and  Subclavian  Arteries.  Re- 
covery. 

Dr.  H.  R.  Wharton  records  (The  Medical  News,  April  9,  1887)  the  history 
and  results  of  treatment  of  a  case  operated  upon  by  Professor  J.  Ashhurst,  Jr., 
at  the  University  College  Hospital,  on  November  13, 1886.  The  right  common 
carotid  was  ligatured  with  catgut  above  the  omohyoid  muscle,  after  which 
the  subclavian  of  the  same  side  was  secured  just  outside  the  anterior  scalene 
muscle.  Silver  sutures,  drainage  tubes,  and  an  oiled  lint  dressing  were  used. 
Neither  unpleasant  cerebral  symptoms  occurred,  nor  did  improvement  in  the 
aneurism  at  first  take  place.    In  a  few  days,  however,  the  aneurismal  tumor 


256 


PKOGKESS   OF   MEDICAL  SCIENCE. 


became  smaller,  the  dyspnoea  and  dysphagia  markedly  diminished,  and  the 
patient  could  sleep  in  the  recumbent  posture.  No  radial  pulse  was  detectable 
even  when  discharged  two  months  after  operation.  Examination  at  that  time 
showed  only  the  merest  traces  of  the  previous  trouble,  so  slight,  indeed  as  to 
warrant  the  belief  that  a  complete  cure  has  resulted.  The  recorded  cases  of 
this  operation  are  examined  and  commented  upon,  the  results  of  consecutive 
ligation  compared,  and  the  opinion  expressed  that  the  simultaneous  ligation 
of  the  right  carotid  and  subclavian  arteries  for  innominate  aneurism  "  is  a  more 
efficient  and  safer  procedure  than  consecutive  ligation  of  these  vessels." 

Three  Cases  of  Ligature  of  the  External  Carotid  Artery,  in  two 
of  which  both  vessels  were  tied  simultaneously. 

Dr.  Jos.  D.  Bryant  (The  Medical  News,  May  14,  1887),  in  a  lengthy  paper, 
well  worthy  of  a  careful  perusal,  sums  up  with  the  following  conclusions:  1. 
Ligature  of  the  external  carotid  artery,  together  with  independent  ligature  of 
the  branches  arising  from  the  first  inch  of  its  course,  is  a  safe  and  commend- 
able operation.  2.  When  the  facial  and  lingual  arteries  do  not  arise  singly, 
or  by  a  common  trunk,  from  the  first  inch  of  the  course  of  the  external  carotid, 
the  branches  arising  at  the  point  of  bifurcation  of  the  common  carotid  should 
be  tied.  3.  Simultaneous  ligature  of  both  external  carotids  is  a  rational  pre- 
paratory measure  for  operations  involving  the  parts  supplied  ty  their  branches 
when  dangerous  hemorrhage  is  feared.  If  the  pharynx  be  involved,  the 
ascending  pharyngeal  branches  should  be  ligatured  also.  4.  Simultaneous 
ligature  is  advisable  as  a  final  expedient  to  diminish  the  rapidity  of  the  devel- 
opment of  extensive,  malignant  growths  when  they  are  nourished  by  the 
branches  of  the  external  carotids.  5.  Ligature  of  one  or  both  external  carotids 
for  the  cure  of  aneurismal  formations  of  the  branches  of  the  same  is  not 
feasible  as  an  independent  curative  measure.  6.  Ligature  of  the  common 
carotid  should  not  be  done  for  the  cure  or  for  the  arrest  of  morbid  conditions 
involving  the  external  carotid  or  its  branches,  except  as  a  final  resort. 

The  Treatment  of  Old  Dislocations  of  the  Elbow. 

Dr.  L.  A.  Stimson  reports,  in  The  Medical  News  for  April  2,  1887,  a  case 
in  which  arthrotomy  was  resorted  to,  and  upon  the  reproduction  of  the  dis- 
placement, excision  of  the  joint  was  done  two  months  after  the  first  operation. 

Attention  is  called  to  the  adhesions  formed  by  the  remains  of  the  lateral 
ligaments  and  adventitious  cicatricial  bands  between  the  olecranon  and 
humerus,  which  take  place  so  far  up  and  behind  the  centre  of  motion  that 
reduction  can  only  be  effected  by  a  greater  degree  of  force  than  originally 
produced  rupture  of  the  articular  ligaments.  Stripping  up  of  the  periosteum 
on  the  dorsum  of  the  humerus  by  the  head  of  the  radius  occasionally  takes 
place,  with  a  consequent  formation  of  bone  greatly  interfering  with  reduction. 
Removal  of  pressure  from  a  growing  epiphysis—  i.  e.,  that  of  the  capitellum  of 
the  humerus — may  result  in  an  overgrowth  of  this  process  in  the  young,  while 
elongation  of  the  neck  of  the  radius  may  take  place  from  the  same  cause, 
both  of  these  conditions  preventing  reduction.  Fractures  of  portions  of  the 
coronoid  process,  the  head  of  the  radius,  or  of  the  epitrochlea,  may,  by  subse- 


OPHTHALMOLOGY. 


257 


quent  bony  adhesions  in  new  sites,  present  insuperable  obstacles  to  replace- 
ment of  the  articular  surfaces. 

Stimson,  in  his  arthrotomy,  made  a  single,  instead  of  the  usual  bilateral 
incision — which  latter  procedure  he  announces  he  intends  adopting  in  the 
future — divided  the  olecranon,  separated  adhesions,  reduced  the  luxation, 
and  then  sutured  the  divided  bones  with  silkworm  gut.  Owing  to  the  strain 
exercised  upon  the  olecranon  by  the  tense  triceps  muscle,  the  elbow  had  to 
be  fixed  at  an  angle  of  145  degrees,  a  position  which  doubtless  determined 
the  redisplacement. 

Dr.  Stimson  concludes  by  stating  his  acceptance  of  the  rules  formulated  by 
Albert  for  cases  of  old  backward  luxation  of  the  elbow,  viz.,  rupture  or  tenoto- 
mize  adhesions  in  the  elderly,  and  if  reduction  then  fails,  forcibly  flex  the 
elbow  to  a  right  angle,  with  or  without  fracture  of  the  olecranon,  and  allow 
ankylosis  to  occur.  In  younger  subjects  divide  subcutaneously  all  bands, 
and  even  the  triceps,  to  avoid  fracture  of  the  olecranon;  but  if  the  bones  can- 
not then  be  replaced,  arthrotomy  should  be  done  by  two  lateral  incisions. 
Finally,  if  everything  fail,  excise  the  joint. 


OPHTHALMOLO  GY. 


UNDER  THE  CHARGE  OF 

L.  WEBSTER  FOX,  M.D., 

OPHTHALMIC  STJBGEON  TO  THE  GEKMANTOWN  HOSPITAL,  PHILADELPHIA.. 


Ophthalmoplegia  Externa  Acuta. 

In  the  Edinburgh  Medical  Journal  for  March  Drs.  Berry  and  Bramwell 
report  a  case  of  ophthalmoplegia  externa  acuta  in  a  child  of  two  and  a  half 
years,  probably  due  to  a  scrofulous  lesion  of  the  pons  Varolii,  with  subsequent 
recovery.  The  authors  admit  that  the  exact  nature  of  the  lesion  must,  to 
some  extent,  be  a  matter  of  conjecture,  but  were  disposed  to  think  that  it  was 
probably  tubercular  from  the  sudden  nature  of  the  attack  and  the  clinical  his- 
tory of  the  case.  The  ocular  symptoms  manifested  themselves  as  follows : 
Almost  complete  ptosis  of  both  lids,  inability  to  elevate  the  eyes,  complete  loss 
of  the  power  of  depressing  them ;  the  internal  rectus  of  the  right  eye  was 
absolutely,  and  that  of  the  left  almost  completely,  paralyzed ;  absolute  diver- 
gence of  the  eyeballs,  the  pupils  from  four  to  five  mm.  in  diameter,  which  con- 
tracted promptly  to  light.  There  Avere  no  visible  changes  of  the  fundus  oculi. 
Dr.  Berry's  diagnosis  was  paralysis  of  the  third  and  fourth  nerves  and  paresis 
of  the  sixth — i,  e.,  almost  complete  ophthalmoplegia  externa. 

By  careful  examination,  no  loss  of  sensation  or  derangement  of  motion 
could  be  elicited  other  than  could  be  accounted  for  by  the  general  apathetic 
and  drowsy  condition  of  the  patient.  The  authors  localized  the  lesion  at  the 
top  of  the  pons  Varolii  and  in  the  neighborhood  of  the  aqueduct  of  Sylvius, 
from  the  fact  that  the  muscles  supplied  by  the  third,  fourth,  and  sixth  nen  ea 
on  both  sides  were  involved  and  vision  unaffected.    The  prompt  pupillary 

NO.  CLXXXVII.— JULY,  1887.  17 


258 


PKOG-RESS  OF   MEDICAL  SCIENCE. 


reaction  demonstrated  that  it  was  not  the  trunk  of  the  third  nerve  but  only 
those  nuclei  connected  with  the  external  muscles  of  the  eyeball  which  were 
implicated.    The  fifth  nerve  was  apparently  unaffected. 

The  authors  bring  to  their  support  the  researches  in  the  localization  of  the 
motor  functions  of  the  eye  by  Henson  and  Volckers,  Kahler,  Pick,  and  Ferrier. 
The  labors  of  Henson  and  Volckers  have  established  the  fact  of  a  differentia- 
tion of  centres  of  the  third  pair  of  nerves,  so  that  each  of  the  ocular  muscles, 
the  levator,  the  superior,  inferior,  and  internal  recti,  and  the  inferior  oblique, 
has  a  distinct  and  localized  nuclear  origin  beneath  the  floor  of  the  aqueduct 
of  Sylvius;  moreover,  the  centres  for  the  reflexes  of  light  and  accommoda- 
tion (the  iris  and  ciliary  muscle  are  not  only  distinct  from  the  preceding  but 
from  each  other)  are  placed  further  forward  toward  the  summit  of  the  third 
ventricle.  From  these  anatomical  differences  of  origin  we  can  understand 
how  there  may  be  ophthalmoplegia  externa  whilst  the  pupillary  and  ciliary 
reflexes  are  perfectly  normal ;  and  also  how  the  reflex  to  light  may  be  abol- 
ished with  conservation  of  the  accommodative  reflex  as  in  the  "  Argyll- 
Robertson  pupil." 

The  differential  diagnosis  between  ophthalmoplegia  of  nuclear  origin  and 
that  arising  from  peripheral  lesion  depends  on  the  following  symptoms :  In 
the  first  instance  there  is  a  slow,  gradual,  and  progressive  suppression  of  ocular 
motility,  with  a  moderate  degree  of  ptosis  that  may  be  temporarily  overcome 
by  the  will,  and  with  normal  pupillary  and  accommodation  reflexes.  In 
paralysis  of  peripheral  origin,  the  failure  of  function  is  monolateral,  sudden, 
subject  to  no  changes  or  intermissions,  and  if  existing,  the  ptosis  is  not  con- 
trollable by  the  will.  This  latter  phenomenon  finds  its  explanation  in  the 
clinical  and  physiological  fact  that  the  levator  is  the  only  one  of  the  ocular 
muscles  whose  relations  with  the  cortex  have  been  established. 

The  patient  recovered  under  the  internal  administration  of  the  iodide  of 
potassium. 

Imperfect  Convergence  in  Exophthalmic  Goitre. 

P.  J.  Mobius  {Centralbatt  fur  Nervenheilhunde)  finds  a  subnormal  con- 
verging power  in  patients  with  Basedow's  disease,  the  remarkable  fact  being 
that  the  imperfection  is  independent  of  the  proptosis,  since  in  two  cases  when 
the  proptosis  was  marked,  convergence  was  normal,  and  in  the  other  six  cases, 
varying  greatly  in  the  degree  of  proptosis,  the  imperfect  convergence  was 
decided.  The  author  concludes  that  the  phenomenon  is  due  to  the  nervous 
debility,  and  cites  Perinaud,  who  found  a  reduced  power  of  convergence  in 
neurasthenic  patients. 

Syphilitic  Arteritis  of  a  Eetinal  Artery. 

In  the  Correspondenz-blatt  filr  Schweizer  Aerzte,  Haab  reports  a  case 
believed  to  be  unique,  of  pronounced  arteritis  of  one  of  the  branches  of  the 
retinal  artery,  due  to  syphilis.  The  trunk  of  the  artery  showed  spots  of 
brilliant  whiteness,  often  resembling  white  scales,  whilst  in  the  smaller  sub- 
divisions of  the  branches  the  change  was  shown  throughout.  These  lesions 
were  markedly  lessened  by  constitutional  treatment  directed  against  the 
general  syphilitic  condition. 


OPHTHALMOLOGY. 


259 


Physiological  action  of  Atropia  on  the  Iris. 

Dr.  H.  Holtzke  in  Klinische  Monatsblatter  for  March,  asserts  that  mydri- 
asis of  the  pupil  following  instillations  of  atropia,  is  caused  by  paralysis  of 
the  nerve  endings  of  the  oculomotorius  only.  His  statement  is  based  upon 
experiments  made  upon  lower  animals,  where  the  pupil  had  been  dilated  by 
atropia  and  the  sympathetic  nerve  severed;  the  pupil  immediately  after  the 
operation  contracted;  by  the  application  of  faradization  dilatation  follows. 
Contraction  and  dilatation  of  the  pupil  have  been  observed  in  a  non-atro- 
pinized  eye,  where  the  same  experiment  has  been  made. 

Stilling  advances  the  argument  that  atropine  not  only  paralyzes  the  nerve 
endings  of  the  oculomotorius,  but  also  irritates  the  sympathetic,  and  brings 
to  his  support  the  fact  that  in  paralysis  of  the  third  nerve,  due  to  some  lesion, 
where  we  have  a  certain  amount  of  pupillary  dilatation  (about  five  mm.),  an 
application  of  atropia  will  dilate  the  pupil  still  further  (8  mm.).  He  argues 
that  the  atropia  irritates  the  sympathetic,  thereby  producing  secondary 
mydriasis. 

Holtzke  explains  this  as  follows  :  Inasmuch  as  the  lesion  is  along  the  trunk 
of  the  nerve,  there  still  remains  a  certain  amount  of  force  in  the  ganglion 
cells  situated  in  the  iris  or  anterior  portion  of  the  uveal  tract  or  ciliary  gang- 
lion, which  gives  a  certain  amount  of  remnant  tonicity  to  the  peripheral 
ending  of  the  nerve,  it  being  these  cells  which  the  atropia  affects,  and 
thereby  producing  the  secondary  dilatation.  Cocaine  produces  mydriasis  of 
the  pupil  by  its  irritant  effect  upon  the  sympathetic,  hence  the  secondary 
dilatation  in  an  atropinized  eye.  Our  author  sets  forth  this  fact  in  support  to 
his  primal  assertion  that  atropia  only  acts  physiologically  upon  the  third 
nerve  when  applied  to  the  eye. 

Snow-blindness. 

Dr.  L.  B.  Graddy,  of  Omaha,  Neb.,  had  under  observation  six  patients 
suffering  from  snow-blindness.  They  were  hunters,  following  their  occupa- 
tion in  a  district  covered  with  snow.  The  intense  glare  of  the  sun  reflect- 
ing from  the  snow  produced  the  visual  defect.  The  first  manifestation  of 
disturbed  vision  was  their  inability  to  outline  game  (wild  geese)  below  the 
horizon.  The  visual  defect  increased  to  such  a  degree  that  landmarks  which 
guide  men  on  the  plains,  faded  rapidly  away,  and  it  was  with  difficulty  that 
they  found  their  way  into  camp.  Forty-eight  hours  after  the  attack,  the 
victims  were  found  by  Dr.  Graddy  suffering  intensely  with  photophobia, 
lachrymation,  conjunctivitis,  ciliary  neuralgia  and,  in  two  cases,  complicated 
by  a  narrow,  horizontal  band  of  superficial  keratitis.  The  patients  described 
their  condition  as  if  enveloped  in  a  white,  heavy  mist.  As  their  faces  were 
sunburned,  Dr.  Graddy  assumes  that  the  pathological  condition  of  the  con- 
juctiva  and  cornea  was  of  the  same  character,  and  the  blindness  due  to  mole- 
cular change  in  the  retina,  caused  by  over-stimulation. 

The  treatment  instituted  was  soothing  external  applications  and  dark 
rooms.    Eecovery  followed,  with  useful  vision. 

Indians  and  trappers  have  an  ingenious  way  of  protecting  vision,  where 
the  glare  is  intense,  by  applying  around  the  eyes,  and  over  the  cheeks,  a 
gunpowder  paste,  or  goggles  made  of  the  untanned  skin  of  animals,  fitting 
closely  around  the  orbit. 


260 


PROGRESS   OF   MEDICAL  SCIENCE. 


Myopia  in  the  Schools  of  Stockholm. 

In  an  examination  of  1446  school  children  of  Stockholm,  Professor  Johan 
Nidmark  found  no  myopia  in  children  of  six  or  seven  years  of  age,  whilst 
among  scholars  of  eight  and  nine  there  was,  among  girls,  but  one  case; 
among  boys  14  per  cent. ;  at  sixteen,  33  per  cent,  of  boys  and  girls  were  myopic, 
with  an  average  of  — 2.5  D.  In  the  highest  grades  the  proportion  of  myopes 
among  the  girls  rose  as  high  as  54.28  per  cent.,  with  an  average  degree  of 
— 3.5  D.,  the  frequency  among  boys  not  being  so  great,  one  school  (girls) 
showed  a  frequency  of  66.67  per  cent.,  and  a  mean  of  — 4.16  D.  The  statistics 
show  that  the  injury  is  greater  to  the  eyes  of  girls,  a  result  to  be  expected, 
both  on  account  of  the  comparative  weakness  of  females,  and  the  nature  of 
their  work  outside  of  school. 

Silver  Balls  as  Substitutes  for  the  Vitreous  after  Evisceration. 

In  the  report  of  the  Bristol  General  Hospital  (British  Medical  Journal)  two 
cases  of  the  successful  use  of  hollow  silver  (instead  of  glass)  balls  is  detailed, 
for  the  substitution  of  artificial  vitreous  after  evisceration,  by  Mr.  W.  P. 
Keall.  The  evisceration  was  thoroughly  performed  under  antiseptic  pre- 
cautions. The  ball  was  of  a  size  easily  enclosed  by  the  sclerotic.  The  open- 
ing in  the  sclerotic  was  made  just  outside  of  the  sclerocorneal  margin  in  a 
horizontal  and  curved  direction,  whilst  that  of  the  conjunctiva  was  vertical, 
in  order  more  effectually  to  close  the  hollow  of  the  eye.  The  wounds  were 
stitched  with  fine  silk  thread.  The  dressing  was  a  pad  of  boracic  lint  moist- 
ened with  carbolic  lotion.  No  pain  was  experienced  from  the  pressure  of  the 
balls,  and  in  a  few  weeks  all  inflammation  and  discomfort  had  disappeared. 

Gouty  Affections  of  the  Eye. 

M.  Zychan  (Recueil  d'  Ophthalmologic)  describes  the  ocular  symptoms  con- 
sequent upon  gout.  The  sclerotic  is  most  frequently  attacked,  though  the 
lachrymal  ducts,  the  lids,  and  other  parts  are  sometimes  affected ;  vascular 
congestion  and  swelling  are  usually  the  most  noticeable  objective  symptoms; 
calcareous  deposits  have  been  found  under  the  conjunctiva  of  the  upper  lids 
near  the  margin,  producing  by  the  friction  (as  in  trachoma)  irritation  of  the 
conjunctiva  of  the  globe,  photophobia,  etc.  The  deposits  may  be  extracted 
or  picked  out  with  any  sharp  instrument.  If  dry  eczematous  scales  form  upon 
the  lids,  with  intense  itching,  the  author  recommends  dusting  the  parts  with 
calomel  or  calomel  and  morphine  combined.  The  capillary  degeneration  of 
gouty  subjects  is  shown  by  conjunctival  hemorrhages  and  extravasations. 

Transplantation  of  Babbit's  Eye  into  the  Human  Orbit. 

Dr.  Charles  H.  May  reports  the  failure  of  an  attempt  of  this  kind  in  the 
Archives  of  Ophthalmology  for  March,  1887.  The  attempt  is  noticeable  only 
because  every  circumstance  attending  the  whole  proceeding  was  as  favorable 
to  success  as  desired.  The  patient's  health  was  all  that  could  be  wished,  the 
operation  was  done  with  skill  and  care,  and  with  every  precaution,  antiseptic 
and  otherwise,  that  could  be  demanded;  the  subsequent  events  were  all  favor- 


OPHTHALMOLOGY. 


261 


able  to  a  successful  result,  but  on  the  ninth  day  ulceration  of  the  transplanted 
eye  began  to  appear,  and  it  was  removed.  The  muscles  and  optic  nerve  had 
united  more  or  less  firmly,  but  the  mass  of  foreign  tissue  proved  too  great;  its 
nourishment  was  impossible  under  such  circumstances. 

Artificially  Produced  Cataract. 

In  La  Semaine  Medicate,  Messrs.  Bouchard  and  Charrin  state  that  naph- 
thalin  produces  cataract  of  both  eyes  in  rabbits;  it  requires  three  to  four 
weeks,  daily  doses  of  about  twenty-five  grains,  to  produce  this  result. 

In  examining  the  functions  of  the  cochlea,  Dr.  Stein  found  that  the  per- 
sistent action  of  a  high-pitched  tuning  fork  produced  cataract  in  young  por- 
poises in  from  eighteen  to  twenty-four  hours.  The  opacity  of  the  lens  passed 
off  in  time,  but  could  be  reinduced  by  the  tuning  fork.  In  animals  whose 
-ears  had  been  destroyed,  the  cataracts  were  producible  in  two  or  three  hours. 

A  New  Cause  of  Mydriasis. 

Dr.  Kampoldi  {Recueil  d'  Ophthalmologic,  March,  1887)  calls  attention  to 
bronchial  and  pneumonic  affections  as  frequent  sources  of  unilateral  (some- 
times bilateral)  mydriasis.  He  has  noted  the  fact,  especially  after  the  patient 
has  passed  a  sleepless  night  from  cough,  and  explains  the  phenomenon  as  a 
result  of  irritation  of  the  cervical  sympathetic  which  supplies  the  radiating 
fibres  of  the  iris. 

Cataract  Extraction  without  Iridectomy. 

In  the  Archives  of  Ophthalmology  for  March,  1887,  Dr.  H.  Knapp  reviews  the 
reasons  for  and  against  a  preceding  iridectomy  in  cataract  extraction.  His  con- 
clusion is:  "Simple  extraction  is  an  operation  of  the  highest  order,  and  prac- 
ticable in  the  majority  of  cases  with  the  same  degree  of  safety  as  the  extrac- 
tion combined  ivith  iridectomy.  In  a  considerable  minority,  however,  the 
latter  method  is  preferable;  in  a  number  of  cases  the  indications  for  the 
iridectomy  manifest  before,  in  others  only  during,  the  operation."  He  con- 
cludes that  an  iridectomy  should  be  made  when,  from  fluidity  of  the  vitreous 
and  rupture  of  the  suspensory  ligament,  or  from  insufiicient  section,  the 
vitreous,  instead  of  the  lens,  presents ;  when  the  iris  has  been  injured,  when 
the  sphincter  is  unyielding,  when,  subsequent  to  the  expulsion  of  the  lens, 
the  iris  proves  irreducible. 

Of  the  twenty-nine  cases  detailed  which  served  as  clinical  proof  of  the 
results,  there  were  eighteen  "perfect  or  ideal  recoveries" — i.  e.,  the  pupil  was 
central  and  movable,  and  unobstructed  by  inflammatory  products.  The 
advantages  of  the  operation  without  iridectomy  are  evident ;  there  is  a  normal 
and  active  pupil,  a  natural  appearance  of  the  eye,  increased  acuteness  and 
better  eccentric  vision,  etc.  On  the  other  hand,  the  operation  is  somewhat 
more  difficult,  the  section  larger,  the  lens  less  easily  expelled;  there  is  greater 
danger  of  prolapse  of  the  iris  and  posterior  synechia?. 

Irrigation  of  the  Anterior  Chamber  after  Cataract  Extraction. 

In  Annates  d'  Oculistique  for  January,  1887,  Dr.  Grandclement,  of  Lyon, 
reviews  the  method  adopted,  and  the  nature  of  the  liquid  used  by  MacKeown, 


262 


PROGRESS  OF  MEDICAL  SCIENCE. 


Wicherkiewicz,  and  Panas  for  irrigation  of  the  anterior  chamber  after  cataract 
extractions.  Wicherkiewicz  reduced  the  practice  to  a  method  for  operations 
upon  immature  cataracts,  instead  of  artificial  maturation.  Wecker  made 
these  injections,  containing  a  solution  of  the  salicylate  of  eserine,  in  order  to 
secure  pupillary  contraction  and  to  prevent  prolapse  of  iris;  Panas  requiring 
not  only  cleansing,  but  also  antiseptic  properties. 

Inasmuch  as  the  usual  antiseptics,  such  as  the  bichloride  of  mercury  or 
phenic  acid,  were  too  irritating,  he  employed  the  biniodide  of  mercury  (0.05 
gramme  to  1000  grammes,  with  20  grammes  alcohol,  at  90°),  which  he  found 
successful,  patients  usually  recovering  in  seven  days.  Grandclement  per- 
formed four  cataract  operations,  following  the  details  as  suggested  by  Panas. 
excepting  the  strength  of  the  solution,  which  was  but  half  strength,  for  fear 
of  producing  too  much  irritation. 

In  the  first  case  the  solution  was  used  thoroughly.  The  vision  immediately 
following  the  irrigation  was  excellent,  but  in  twenty-four  hours,  and  still 
more  marked  on  the  second  day,  the  cornea  was  striated  and  lacked  trans- 
parency. The  iris  and  capsular  sac  became  involved  and  the  final  result  was 
not  brilliant. 

The  three  cases  following  responded  more  favorably  to  the  treatment.  Our 
author  found  the  intra-capsular  irrigation,  as  practised  with  Panas'  solution, 
dangerous,  and  according  to  experiments  made  upon  rabbits  by  Drs.  Bet- 
tremieux  and  Vassaux,  disciples  of  Panas,  the  salts  of  mercury  should  be 
abandoned.  For  operations  upon  immature  cataracts  our  author  now  uses 
boiled  and  sterilized  water,  having  abandoned  all  antiseptic  liquids  as  danger- 
ous and  useless,  there  being  no  microbes  in  the  eye ;  besides,  the  recent  investi- 
gations and  experiments  of  Prof.  Sattler  prove  that  Panas'  solution  is  absolutely 
too  weak  to  kill  the  numerous  microbes  which  he  found  in  the  lachrymal  sac 
and  secretions  of  the  conjunctiva  of  individuals  suffering  from  catarrhal  in- 
flammation of  the  lachrymal  ducts.  To  destroy  the  microbes  a  solution  four 
times  the  strength  would  be  required — much  too  irritating  to  apply  to  the  eye. 
Boracic,  salicylic  acid,  and  other  substances  reputed  antiseptic,  Sattler  found 
useless  in  the  destruction  of  micrococci. 

With  patients  having  cataracts  and  suffering  from  catarrhal  inflammation 
of  the  lachrymal  canal,  our  author  suggests  the  application  of  the  sublimate, 
20  centigrammes  to  1000  grammes,  for  a  shorter  or  longer  time,  to  the  palpe- 
bral aperture  until  a  violent  conjunctivitis  is  produced,  this  is  then  mastered 
by  astringent  washes,  and  the  operation  for  cataract,  or,  what  is  still  safer,  a 
preliminary  iridectomy  performed.  Five  or  six  weeks  subsequently  the  lens 
may  be  removed  through  the  scar-tissue,  which  must  be  less  favorable  to  the 
evolution  of  morbid  germs.  Our  author  has  followed  this  method  with  good 
results,  not  depending  upon  boracic  acid,  which  seems  too  much  in  vogue 
to-day.  The  reviewer  has  found  boroglyceride,  fifty  per  cent,  solution,  a 
most  efficient  remedy  is  cases  as  described  above. 

TitAXSPLAlSTATIOK  OF  THE  COKNTSA. 

In  Zahender's  Kli?iische  Monatsbldtter  for  February,  1887,  Prof.  Adimtjk 
reports  his  attempts  at  corneal  transplantation  into  human  eyes,  emphasizing 
the  recommendation  that  an  adjacent  portion  of  sclerotic  be  also  transplanted. 


OPHTHALMOLOGY. 


263 


This  is  in  view  of  the  fact  that  the  cornea  is  nourished  from  its  periphery, 
and  that  the  sclerotic  heals  more  rapidly  than  the  cornea.  It  therefore 
became  necessary  to  choose  some  animal  having  an  eye  small  enough  to 
enable  the  operator  to  procure  a  piece  (by  trephining)  of  the  requisite  tissues 
and  size.  Three  attempts  were  made  with  rats'  eyes ;  the  tissues  proved  too 
thin  and  weak  to  withstand  the  intraocular  pressure  of  the  human  eye.  But 
there  was  union  and  healing  of  the  transplanted  part,  and  this  gave  encour- 
agement to  other  attempts. 

Five  trials  were  made  with  hen's  eyes.  Two  ulcerated,  and  three  grew 
firmly  in  place,  but  these  cases  subsequently  passed  out  of  observation,  and 
no  definite  results  can  be  stated.  The  author,  however,  urges  that  his  partial 
success  renders  the  method  of  including  a  bit  of  the  sclera  with  the  trans- 
planted piece  a  prerequisite  of  success.  The  method  whereby  this  opaque 
part  subsequently  becomes  transparent  by  a  spontaneous  process  is  hard  to 
believe.  It  is  evident  that  the  success  of  the  endeavors  must  depend  upon  a 
more  perfect  technique.  Personal  disappointments  and  the  scepticism  of 
others  have  not  discouraged  v.  Hippie,  who  recently  successfully  ingrafted  a 
rabbit's  cornea  (4  mm.)  in  the  opaque  cornea  of  a  girl  seventeen  years  old. 

20 

The  visual  acuity  at  the  end  of  eight  days  was  —     The  investigations  of 

cc 

Leber  upon  the  liquid  changes  of  the  eye  have  taught  us  that  the  transparency 
of  corneal  tissue  is  only  protected  by  the  intact  state  of  Descemet's  membrane, 
hence  the  transplantation  is  made  possible,  only  if  the  endothelium  of  this 
membrane  preserves  its  integrity.  If  the  membrane  is  wounded  it  rolls  upon 
itself,  and  failure  is  the  result.  The  method,  which  is  difficult  and  delicate, 
is  applicable  only  to  non-adherent  leucomas,  according  to  von  Hippie. 

Inflammation  of  the  Lachrymal  Canal. 

Dr.  Montanelli  {Bolletino  d'  Oculistica)  reports  that  two  cases  of  dacryo- 
cystitis, which  proved  rebellious  to  the  usual  line  of  treatment,  responded 
promptly  to  the  daily  irrigation  of  the  canal  of  a  solution  of  boracic  acid  (40 
in  1000)  with  one  gramme  of  salicylic  acid.  The  injections  were  made  with 
a  perforated  nozzle  introduced  in  the  upper  lachrymal  duct,  and  this  probe 
attached  to  a  rubber  tube  terminating  in  a  reservoir  placed  90  centimetres 
above  the  level  of  the  eye. 

Ocular  Injuries  caused  by  the  Obstetric  Forceps. 

Berger  {Archives  fur  Augenheilkunde,  March,  1887)  reports  a  case  of  ocular 
injury  caused  by  obstetrical  forceps,  which,  from  its  rarity,  attracts  attention. 
The  levator  palpebral  was  so  injured  that  the  child  (of  four  years)  suffered 
with  marked  ptosis,  and  an  almost  complete  lack  of  power  of  the  rectus  supe- 
rior. Fundus  oculi  was  normal,  the  refraction  hyperopic  and  astigmatic,  vision 
20 

— — .  Three  other  cases  of  ocular  injuries  by  forceps  are  all  that  are  recorded 

in  ophthalmic  literature.  These  are  by  Steinheim,  in  the  Deutsche  mcdizin- 
ische  Wochenschri/t,  1883,  No.  17. 


264: 


PKOGRESS  OF  MEDICAL  SCIENCE. 


Incision  of  Swollen  Optic  Nerve  Sheath,  and  Etiology  of 
"Choked  Disk." 

Mr.  Brudenell  Carter  [Lancet,  March  26, 1887)  reported  to  the  Medical 
Society  of  London  an  interesting  and  successful  instance  of  incision  of  the 
nerve  sheath,  and  escape  of  the  contained  fluid,  in  a  case  of  swollen  optic 
disk.  Under  iodides  and  mercury  no  improvement  had  taken  place,  but  the 
•symptoms  rapidly  grew  worse.  Vision  was  already  seriously  threatened.  The 
operation  was  preceded  by  a  division  of  the  external  rectus,  and  the  sheath  of 
the  optic  nerve  was  exposed  by  rotating  the  eye  inward,  and  the  incision 
made.  There  was  immediate  relief  from  headache.  In  ten  days  the  swelling 
of  the  optic  disk  had  become  reduced  by  one-half,  and  the  recovery  was 
uninterrupted. 

The  case,  he  thought,  goes  far  to  prove  that  the  pathology  of  swollen  optic 
disk  is  primarily  dropsical,  and  only  secondarily  neuritic.  Dr.  Carter  argued 
that  there  was  a  descent  of  fluid  from  the  subarachnoid  space  to  the  space 
between  the  dural  and  pial  sheaths  of  the  optic  nerve,  and  from  this  cause 
resulted  compression  of  the  nerve,  and  impeded  venous  circulation. 

Readers  interested  in  this  question  of  the  etiology  of  optic  neuritis,  will 
find  a  thorough  r'esum'e  of  Deutschman's  researches  and  experiments  in  rela- 
tion thereto  in  the  Ophthalmic  Review  for  April,  1887.  Deutschman  makes  it 
clear  that  the  so-called  choked  disk  is  not  pathologically  distinct  from  other 
forms  of  papillitis,  and  that  the  inflammatory  process  in  the  nerve  is  generally 
an  ascending,  rather  than  a  descending  one.  The  conclusion  reached  is  that 
papillitis  does  not  depend  upon  pressure,  but  results  from  an  irritating  fluid 
passing  from  the  cranial  cavity,  and  arrested  at  the  bulbar  end  of  the  optic 
nerve,  producing  there  an  infective  action.  This  conclusion  would,  therefore, 
as  necessarily  demand  the  surgical  procedure  above  described,  as  if  pressure, 
instead  of  being  only  a  subsidiary  cause,  were  in  fact  the  sole  cause.  In 
cases,  therefore,  when  loss  of  vision  is  threatened  from  papillitis  of  any  kind, 
the  indication  points  to  immediate  incision  of  the  optic  nerve  sheath  and 
drainage  of  the  dammed-up  retrobulbar  infecting  fluid. 

Ophthalmia  Neonatorum. 

The  fifth  of  Dr.  C.  Bell  Taylor's  clinical  lectures  on  diseases  of  the  eye 
{Lancet,  April  16,  1887)  is  devoted  to  ophthalmia  neonatorum,  and  is  a 
succinct  account  of  the  fearful  consequences  of  the  common  neglect  of 
obstetricians  to  give  but  an  instant's  attention  to  a  simple  prophylactic 
measure. 

Of  630  cases  treated  in  the  early  stages  by  Professors  Horner,  Schweigger, 
and  Hirschberg,  every  one  recovered  with  absolutely  perfect  sight,  whilst  of 
120  cases  treated  by  the  same  physicians,  but  only  in  the  later  stages,  49  became 
wholly  blind.  Of  the  300,000  blind  people  in  Europe,  from  one-third  to  one- 
half  are  so  from  simple  neglect  of  an  absolutely  certain  and  well-known  pre- 
caution. 

Crede's  method — a  two  per  cent,  solution  of  nitrate  of  silver  dropped  into 
the  eyes  of  all  newborn  infants — should  be  a  public  law,  neglect  of  which 
should  debar  a  physician  or  midwife  for  all  time.  It  is  an  old  warning,  but 
it  is  one  that  ignored  daily  produces  such  a  stupendous  amount  of  misery  that 
it  seems  always  a  propos  again  to  call  attention  to  it. 


OTOLOGY. 


265 


OTOLOGY. 


UNDER  THE  CHARGE  OF 

CHAELES  H.  BUKNETT,  M.D., 

PROFESSOR  OF  OTOLOGY  IN  THE  PHILADELPHIA  POLYCLINIC  AND  COLLEGE  FOR  GRADUATES  IN  MEDICINE,  ETC. 


Sarcoma  of  the  Concha. 

Dr.  M.  D.  Jones,  of  St.  Louis  (St.  Louis  Courier  of  Medicine,  Feb.  1887), 
reports  the  following  interesting  case  of  this  rare  affection  : 

A  negro,  aged  seventeen,  had  a  lobulated  non-pedicellate  tumor  about  the 
size  of  a  chestnut,  springing  from  the  centre  of  the  right  concha,  filling  it  and 
hiding  the  orifice  of  the  external  meatus.  The  mass  looked  glossy,  and  at 
first  was  mistaken  for  a  huge  polyp  protruding  from  the  meatus.  The  patient 
stated  that  two  months  previously  he  noticed  a  pimple  on  his  ear,  which  itched 
greatly.  He  repeatedly  scratched  it  and  removed  a  scab  from  it,  which  "was 
followed  each  time  by  moderate  bleeding.  Suddenly  the  pimple  began  growing, 
and  in  a  few  weeks  attained  its  large  size.  At  no  time  was  there  pain  about  the 
auricle.  The  growth  was  removed  by  a  cold  wire  snare,  and  proved  to  be  a 
small  spindle-celled  sarcoma.  Fibro-sarcoma  of  the  lobule  is  not  rare  and  is 
generally  met  in  the  negro.  Sarcoma  of  the  auricle,  however,  is  rare,  and  the 
case  reported  here  makes  the  third  one  where  the  cancer  was  found  invading 
the  pinna  primarily. 

On  the  Management  of  Perforations  of  the  Membrana  Tympani. 
Sir  Wm.  B.  Dalby  believes  that  perforations  possess  individualities  of  their 
own.  (British  Med.  Journal,  March  12,  1887.)  They  display  an  "infinite 
variety,"  in  their  occasional  rapid  healing,  in  their  tolerance  at  times  of  treat- 
ment, and  again  their  intolerance  and  a  great  susceptibility  to  climate  and 
diet,  especially  to  stimulants.  It  is  maintained  that  in  all  cases  of  aural 
discharge,  in  young  children,  the  membrana  is  usually  perforated.  When 
examined,  a  few  weeks  after  the  discharge  has  ceased,  the  perforations  will 
be  found  to  have  closed.  We  must,  therefore,  "  admit  that  during  infant-life 
the  membrane  is  extremely  prone  to  become  perforated,  and,  happily,  equally 
prone  to  heal."  It  is  also  worthy  of  note  that  the  majority  of  these  children 
hear  well  when  they  grow  up.  Although  this  fortunate  ending  is  often  due 
in  part  to  the  fact  that  there  has  been  no  local  interference,  "  it  does  not 
follow  that  nothing  should  be  done  for  recent  infantile  perforations  of  the 
membrane."  They  are  better, however,  without  treatment  "if  such  treatment 
includes  mineral  astringents  in  solution."  Sulphate  of  zinc  and  acetate  of 
lead  lotions  are  worse  than  useless,  as  they  injure  the  ear  as  an  acoustic  organ, 
because  they  "  astringe  the  tympanic  end  of  the  Eustachian  tube,"  prevent 
the  expulsion  of  discharge  from  the  tympanum  through  the  perforation,  and 
permit  it  to  collect  and  become  inspissated.  They  also  cause  cicatrization  of 
the  edges  of  the  perforation,  and  interfere,  therefore,  with  the  process  of  repair 
of  the  hole  in  the  membrane. 

The  treatment  must  consist  in  scrupulous  cleanliness  of  the  middle  and 
external  ear,  the  use  of  vegetable  astringents,  and  the  exclusion  of  air.  This 


266 


PROGRESS   OF   MEDICAL  SCIENCE. 


forms  the  routine  treatment  under  which  recent  perforations  are  most  likely 
to  heal.    The  same  will  apply  to  recent  perforations  in  adults. 

Perforations  of  long  standing  and  with  copious  purulent  discharge,  improve 
under  the  use  of  alcohol  instillations  of  various  dilutions.  In  perforations  of 
small  size  alcohol  generally  proves  irritating  and  painful.  It  is  claimed  by 
our  author  that  boric  acid  and  iodoform,  though  usually  acting  well,  some- 
times, in  chronic  perforations,  cause  pain  in  the  same  side  of  the  head.  Our 
experience  with  iodoform  is  limited  in  comparison  with  our  experience  in  the 
use  of  boric  acid ;  but  as  both  are  known  to  have  local  anaesthetic  properties, 
it  is  difficult  to  see  how  their  use  in  the  ear  can  cause  pain  in  it,  or  in  the 
corresponding  side  of  the  head.  As  a  matter  of  fact,  we  have  never  seen  any 
such  results  from  their  use  in  the  ear,  if  they  are  simply  insufflated.  If  they 
are  blown  in  and  then  packed  down  into  the  fundus  of  the  auditory  canal,  as 
is  the  manner  of  some,  irritation  is  very  apt  to  ensue. 

Therapeutic  Effect  of  Iodol  in  Suppuration  of  the  Ear. 

According  to  Schmidt,  iodol  possesses  the  advantage  over  iodoform  in  being 
inodorous,  less  irritant,  and  in  not  exciting  any  toxic  symptoms  from  its  em- 
ployment on  wounds.  Dr.  Stetler,  of  Konigsberg,  Russia  {Archiv  fur 
Ohrenh.,  Bd.  23,  pp.  264-268),  has  endeavored  to  substitute  iodol  for  iodoform 
in  the  treatment  of  diseases  of  the  ear,  especially  in  purulent  otitis.  It  has 
been  applied  by  him  by  insufflation,  after  a  careful  cleansing  of  the  auditory 
canal,  once  or  twice  a  day,  according  to  the  abundance  of  the  discharge  from 
the  ear.  The  results  of  his  experiments  show  that  iodol  has  much  the  same 
action  as  iodoform.  In  the  clinic  of  Schwartze,  at  Halle,  iodol  has  been  tried 
also.  In  the  same  number  of  the  Archiv  f  Ohrenheilhunde,  there  is  a  report  of 
the  results  obtained  there.  Iodol  being  but  slightly  soluble  in  water,  it  has 
been  used  according  to  the  plan  of  Mazzoni,  viz.,  two  grammes  are  dissolved  in 
a,  mixture  of  sixteen  parts  of  alcohol  and  thirty-four  parts  of  glycerine.  It  has 
been  used  chiefly  in  otorrhcea  complicated  by  caries  of  the  bone.  Compresses 
of  gauze,  dipped  in  the  above  solution,  were  placed  upon  the  diseased  bone, 
after  cleansing,  once  or  twice  daily.  The  results  were  favorable;  both  the 
odor  and  discharge  diminished.  The  formation  of  healthy  granulations  was 
not  hastened  by  its  use.  On  the  whole,  it  does  not  seem  that  iodol  has  much 
of  a  future  in  otology. 

Tinnitus  Aurium,  and  its  Treatment  by  a  New  Method  of 
Alternate  Injection  and  Evacuation  of  Air. 

Admitting  that  we  know  of  no  specific  for  the  cure  of  tinnitus  aurium, 
Dr.  John  Ward  Cousins  maintains  that  the  removal  of  this  symptom  must 
depend  wholly  upon  the  successful  treatment  of  the  special  morbid  process  by 
which  it  is  excited  {British  Med.  Journal,  March  26,  1887). 

In  speaking  of  the  treatment  of  tinnitus  dependent  upon  disease  of  the 
middle  ear,  he  says  "  that  theoretically  the  treatment  of  this  form  of  tinnitus 
is  a  very  easy  matter,  and  simply  consists  in  promoting  free  and  healthy 
communication  between  the  tympanum  and  the  pharynx,  and  so  restoring  the 
normal  balance  of  pressure  on  both  sides  of  the  membrana  tympani."  Pent- 
up  fluids  must  be  removed,  and  the  mucous  membrane  stimulated  to  healthy 


OTOLOGY. 


267 


action.  If  collapse  of  the  membrana  and  immobility  of  the  bones  exist,  our 
efforts  must  be  directed  to  promote  the  normal  elasticity  of  these  parts,  and 
reestablish  their  intrinsic  movements.  If  the  Eustachian  tubes  are  ob- 
structed by  secretion,  our  remedies  must  be  employed  for  the  purpose  of 
clearing  the  canals,  and  restoring  the  normal  condition  of  the  nasopharynx 
and  throat. 

In  the  early  stages  the  use  of  the  simple  air  douche  will  render  good 
service,  but  in  chronic  cases  Dr.  Cousins  prefers  "  the  injection  of  air  and  its 
immediate  evacuation.  Sometimes  the  air  is  medicated  by  the  vapor  of  some 
volatile  substance,  for  the  purpose  of  reducing  the  sensibility  of  the  cavity 
and  stimulating  the  mucous  surface."  To  accomplish  this  purpose,  an 
apparatus  of  his  own  invention  is  employed.  It  consists  of  two  parts:  1.  A 
special  nasal  piece,  for  hermetically  closing  the  nose ;  2.  Two  powerful  hand- 
balls, which  are  connected  with  the  former  by  an  India-rubber  tube.  The 
nasal  piece  is  composed  of  two  tubes,  with  their  extremities  inclosed  in 
inflatable  bags  made  of  very  thin  and  soft  rubber.  The  inflating  tube  has  a 
separate  connection  with  the  lower  part  of  each  bag.  The  hand-balls  are 
fitted  with  recoil  springs,  which  impart  force  and  rapidity  to  their  expansion. 
One  hand-ball  is  marked  for  injection,  the  other  for  evacuation,  and  their 
converse  action  is  obtained  by  simply  reversing  the  valvular  arrangement,  so 
that  the  outlet  valve  is  fixed  to  the  connecting  tube  on  one  side  and  the  inlet 
valve  on  the  other.  The  air  injected  may  be  medicated  by  dropping  some 
selected  fluid  on  cotton  placed  in  a  conical  vulcanite  receptacle  at  the  distal 
end  of  the  injecting  tube.  The  alternate  method  of  inflation  is  claimed  by 
its  author  to  have  many  advantages  over  the  ordinary  methods  of  inflation. 
Sometimes  relief  is  given  by  one  operation — as  it  is,  indeed,  sometimes  by  any 
method — while  numerous  operations  may  be  required  before  relief  is  obtained 
in  other  cases.  It  is  asserted  that  this  method  promotes  the  immediate  dis- 
charge of  pent-up  secretion  in  the  pharynx,  and  aids  in  establishing  the 
drainage  of  the  tympanum.  "  In  chronic  cases  the  mobility  of  the  bony  chain 
has  been  long  impaired  by  the  morbid  condition  of  the  middle  ear ;  but  by 
gentle  repeated  agitation  in  both  directions,  the  adhesions  between  the  ossicles 
are  loosened,  and  their  normal  oscillation  restored,  so  that  sonorous  vibrations 
can  be  again  transmitted  from  the  drum  to  the  fluid  within  the  labyrinth." 

Abscess  in  the  Brain  resulting  from  Disease  of  the  Ear. 

Dr.  Thomas  Barr,  of  Glasgow,  has  contributed  a  most  interesting  and 
valuable  article  on  this  topic,  in  the  British  Medical  Journal  of  April  2, 1887. 

It  is  admitted  at  the  outset  that  where  abscess  of  the  brain  is  not  caused  by 
an  injury,  it  depends  usually  upon  some  preexisting  purulent  centre,  and  this 
is  most  frequently  in  the  ear.  This  is  most  usually  in  the  middle  ear,  and  it 
is  held  that  the  published  accounts  of  internal  ear  inflammation,  as  the  source 
of  cerebral  abscess,  are  erroneous.  The  nature  of  this  disease  is  a  chronic 
purulent  inflammation  in  the  lining  membrane  of  the  tympanic  cavity,  mastoid 
antrum,  and  mastoid  cells.  While  there  is  a  general  consensus  of  opinion 
that  ear-disease  is  the  most  frequent  cause  of  cerebral  abscess,  Dr.  Barr  tries 
to  show,  successfully  we  think,  that  it  is  more  frequently  the  cause  than  is 
even  supposed.    In  a  synoptical  record  of  76  cases  (Sir  William  Gull  and  Dr. 


268 


PKOGRESS   OF   MEDICAL  SCIENCE. 


Sutton,  in  Reynolds's  System  of  Medicine,  1872),  27  cases,  or  more  than  one-third, 
were  set  down  as  due  to  ear  disease.  Lebest  (Virchow's  Archiv,  1856,  vol.  x.) 
gives  1  in  4  as  the  proportion,  based  upon  80  cases  of  cerebral  abscess.  But 
in  many  cases  not  attributed  to  the  ear,  given  by  these  authors,  Barr  claims 
that  the  ear  evidently  had  not  been  examined,  "  while  in  a  goodly  number 
the  disease  was  said  to  have  originated  in  a  blow,  which  may  be  quite  com- 
patible with  its  real  origin  in  ear  disease."  In  10  of  the  cases  in  the  article 
in  Reynolds's  System  of  Medicine,  no  reason  is  given  for  the  cerebral  abscess. 
"  We  know  that  up  to  the  time  at  which  these  articles  were  prepared,  the 
hearing  organ  was  very  little  examined,  either  in  the  clinical  wards  or  in  the 
post-mortem  room."  Coupled  with  the  fact  that  purulent  disease  in  the  ear 
may  exist  without  the  knowledge  of  the  friends  of  the  patient,  or  of  even  the 
patient  himself,  Dr.  Barr  believes  we  are  not  in  a  position  to  state  that  47 
cases  in  these  156  of  cerebral  abscess  are  all  that  were  due  to  chronic  purulent 
disease  of  the  ear.  He  thinks  that  from  what  is  now  known,  that  fully  one- 
half  of  all  cases  of  cerebral  abscess  are  due  to  purulent  disease  of  the  ear. 
"As  medical  men  come  to  use  the  ear-speculum  in  every  case  presenting 
symptoms  of  cerebral  disturbance,  the  frequency  with  which  ear  disease  leads 
to  a  fatal  issue  will  be  found  to  be  greater  than  has  hitherto  been  suspected." 

The  most  frequent  situation  of  the  abscess  seems  to  be  in  the  temporo- 
sphenoidal  lobe  of  the  cerebrum.  In  76  cases  tabulated  by  Dr.  Barr,  55  cases, 
or  73  per  cent.,  were  in  the  so-called  middle  lobe  of  the  brain  ;  13  were  in  the 
cerebellum ;  in  the  cerebrum  and  cerebellum,  4 ;  in  the  pons  Varolii,  2 ;  and 
in  the  crus  cerebelli,  1.  The  disease  is  propagated  from  the  ear  to  the  interior 
of  the  cranium  by  two  ways :  1.  Most  frequently  by  the  roof  of  the  tympanum 
and  mastoid  antrum ;  2.  By  the  inner  wall  of  the  antrum  and  mastoid  cells  to 
the  dura  mater  lining  the  posterior  fossa,  and  to  the  cerebellum.  In  some 
rare  instances  pus  makes  its  way  from  a  cerebral  abscess  into  the  middle  earr 
probably  through  the  tegmen  tympani.  The  "  otorrhcea  cerebralis,"  however, 
of  ancient  writers  cannot  be  accepted,  since  the  ear  disease  and  not  the  cere- 
bral disease  is  the  primary  affection.  Opening  the  cranial  wall  by  means  of 
chiselling  is  regarded  as  productive  of  concussion  to  a  brain  already  very 
sensitive  by  disease. 

"  It  is  quite  clear  that,  in  the  future,  persons  suffering  from  abscess  of  the 
brain  dependent  upon  ear  disease  should  not  be  left  to  die  as  they  have  been 
in  the  past,  without  an  effort  being  made,  by  opening  the  interior  of  the 
cranium,  to  reach  the  brain  and  drain  the  abscess.  How  this  can  be  best 
done  cannot  be  fully  settled  until  further  experience  has  been  gained." 

The  concluding  remark  as  to  prevention  is  worthy  of  attention.  "  When 
every  member  of  our  profession  is  sufficiently  impressed  with  the  importance 
of  chronic  suppurative  inflammation  of  the  middle  ear,  and  prepared  effi- 
ciently to  treat  this  disease  in  all  its  stages,  the  occasion  for  this  operation 
will  probably  seldom  arise." 

A  Case  of  Abscess  of  the  Temporo-sphenoidal  Lobe  of  the  Brain, 
due  to  Otitis  Media,  successfully  Treated  by  Trephining  and 
Drainage. 

The  above  named  case  occurred  in  University  College  Hospital,  under 
the  care  of  Dr.  W.  R.  Gowers,  and  to  which  he  called  Mr.  Arthur  E. 
Baker,  F.R.C.S.,  for  surgical  aid.    {British  Medical  Journal,  Dec.  11,  1886.) 


OTOLOGY. 


269 


The  patient  was  a  man  nineteen  years  old.  In  all  respects  his  health  had 
been  good  until  1875,  when  he  had  scarlatina,  which  left  him  with  a  dis- 
charge of  thin,  yellowish  fluid  from  the  right  ear.  In  August  last  (1886) 
he  suddenly  began  to  feel  unwell  and  complained  of  pain  behind  and  around 
the  right  ear.  In  the  course  of  ten  days  he  took  to  his  bed,  his  temperature 
running  up  to  105°  F.  The  next  day  the  temperature  fell  to  103°  F.,  then  to 
99.4°  F.,  without  constipation  or  diarrhoea.  At  the  time  of  his  admission  to 
the  hospital  there  was  no  impairment  of  the  nervous  system.  There  was, 
however,  double  optic  neuritis,  slight,  but  unequivocal.  The  hearing,  taste, 
and  smell  are  said  to  have  been  normal.  [The  hearing  in  the  right  ear  must 
have  been  somewhat  affected  after  a  chronic  disease  of  over  ten  years. — Ee- 
porter.]  There  was  a  fetid  discharge  from  the  right  ear.  Urine  healthy. 
Evening  temperature  101°  F.  The  next  day  temperature  as  low  as  96°  F. 
and  pulse  52.  On  the  fifth  day  after  admission,  Mr.  Barker  examined  the  ear 
and  found  a  large  perforation  in  the  right  membrana  tympani,  in  the  anterior 
and  upper  segment.  The  middle  ear  was  filled  with  a  thick,  fetid  purulent 
debris.  There  was  no  sign  of  acute  inflammation  or  tenderness  about  the  ear, 
or  mastoid  region. 

From  the  morning  of  the  sixth  day  after  admission,  the  temperature  fell 
steadily  to  97.6°  F.,  on  the  morning  of  the  eighth  day.  It  varied  then  between 
this  and  98.8°  for  a  week  more.  The  optic  neuritis  increased,  and  the  patient 
grew  dull.  He  had  severe  vomiting  without  previous  nausea,  and  his  tem- 
perature sank  to  97.6°  F.  His  pupils  were  now  observed  to  be  unequal,  the 
right  being  more  contracted  and  sluggish  than  the  left.  Xo  headache  and 
no  squint.  The  optic  neuritis  more  marked.  On  September  27th,  twelve 
days  after  admission  to  the  hospital,  the  symptoms  were  more  aggravated,  but 
the  temperature  remained  98°  F.  throughout  the  day.  The  next  day,  Mr. 
Barker  decided  to  open  the  mastoid  antrum  and  middle  ear  and  search  for 
pus  in  the  latter,  and  wash  it  out  and  drain  it,  if  pus  were  present.  "  This 
was  done  in  the  usual  way  with  a  gouge,  at  a  point  about  half  an  inch  above 
and  behind  the  centre  of  the  external  auditory  meatus.  On  opening  the 
antrum  there  was  no  gush  of  pus,  but  some  came  away  on  the  instrument  ; 
on  injecting  the  meatus,  a  quantity  of  curdy  and  very  fetid  material  was 
forced  out  of  the  opening  in  the  bone ;  and  on  inserting  a  syringe  into  the 
latter,  similar  matter  welled  out  of  the  meatus.  Having  then  thoroughly 
washed  out  the  middle  ear  with  carbolic  lotion,  the  whole  area  of  operation 
was  dusted  with  iodoform  and  dressed  with  salicylic  wool,  a  drainage  tube 
being  left  in  the  opening." 

The  next  day  the  patient  was  decidedly  better,  though  still  slightly  drowsy ; 
the  right  pupil  did  not  dilate  as  fully  as  the  left.  Temperature  98.4°  to  99°  F. 
Wound  dressed  with  boric  acid  fomentations,  and  drained  well.  The  next 
day  the  patient  felt  better  and  was  brighter.  There  was  no  pain.  "The 
pupils,  however,  remained  the  same,  and  the  optic  neuritis  was  steadily 
increasing."    Temperature  98.6°  F. 

On  the  third  day  after  the  operation  a  silver  drainage  tube  was  substituted 
for  the  rubber  one,  in  the  mastoid  opening.  On  the  next  day,  the  patient  was 
not  so  well,  having  had  a  restless  night.  There  was  no  pain,  but  the  patient 
vomited  in  the  morning.  Bowels  confined ;  drowsy.  Temperature  9S.8°  to 
97.8°  F.    On  the  third  day  the  patient  was  still  drowsier,  having  been  slightly 


270 


PROGRESS  OF  MEDICAL  SCIENCE. 


delirious  during  the  previous  night.  He  also  vomited,  but  had  neither  head- 
ache nor  squint.  On  the  fourth  day  he  felt  drowsy,  and  on  the  next  day  more 
so.  Temperature  was  normal.  While  the  ear  was  being  syringed  there  was 
well-marked  nystagmus  to  the  left,  in  both  eyes,  which  ceased  immediately  on 
discontinuance  of  syringing.  In  the  evening  the  temperature  rose  to  105°  F., 
and  the  patient  had  a  rigor  lasting  forty-five  minutes.  The  rigor  and  the 
intense  optic  neuritis,  in  connection  with  the  negative  result  of  the  previous 
exploration,  were  held  to  indicate  the  presence  of  a  cerebral  abscess,  and  Mr. 
Barker  was  asked  to  trephine  and  search  for  one  in  the  temporo-sphenoidal 
lobe.  This  was  done  on  the  same  evening.  In  the  first  place,  the  auditory 
canal,  the  mastoid  wound,  and  the  middle  ear  were  washed  out  with  a  solution 
of  carbolic  acid  (1  to  20)  and  then  dusted  with  iodoform.  A  V-shaped  incision 
was  made  by  joining  the  incision  previously  made  over  the  mastoid  by  one 
running  from  behind  and  above,  downward  and  forward.  Beneath  this  flap 
the  bone  was  found  to  be  healthy.  A  spot  was  then  chosen  for  the  pin  of  the 
trephine,  an  inch  and  a  quarter  behind,  and  an  inch  and  a  quarter  above  the 
centre  of  the  meatus  of  the  auditory  canal.  The  region  of  the  foramen  of  the 
mastoid  vein  was  thoroughly  examined  and  found  normal.  This  point  is 
always  examined  by  Mr.  Barker  before  opening  the  skull  in  cases  of  intra- 
cranial suppuration,  because  it  is  claimed  that  "  if  there  be  inflammation  on 
the  posterior  aspect  of  the  petrous  bone,  it  can  hardly  reach  the  cerebellum 
without  forming  a  layer  of  pus  under  the  dura  mater  of  the  lateral  sinus.  If 
this  is  so,  the  pus  will  escape  by  the  mastoid  foramen,  if  the  latter  be  exposed." 

The  trephine  was  then  used  at  a  point  corresponding  to  the  inferior 
posterior  angle  of  the  parietal  bone,  close  to  the  squamosal  suture.  The  dura 
mater  was  found  to  be  quite  normal.  The  membrane  was  then  divided  with 
a  knife  and  turned  back,  when  the  surface  of  the  brain  was  seen  to  be  un- 
affected, nor  was  there  any  fluid  in  the  arachnoid  space. 

The  whole  wound  and  the  opening  made  by  the  trephine  having  been  again 
thoroughly  washed  by  a  strong  solution  of  carbolic  acid  and  dusted  with 
iodoform,  Mr.  Barker  thrust  a  hollow  aspirator-needle,  about  the  size  of  a 
No.  4  catheter,  into  the  temporo-sphenoidal  lobe,  in  a  direction  inward,  for- 
ward, and  downward.  This  was  done  slowly,  and  when  the  point  had  reached 
a  spot  about  half  an  inch  inward  from  the  surface  of  the  brain,  a  bubbling 
sound  was  heard,  followed  by  thick,  yellow,  intensely  fetid  pus,  to  the  extent 
of  four  and  a  half  drachms.  No  more  pus  escaping  through  the  needle,  the 
cortical  wound  was  slightly  dilated,  and  two  or  three  drachms  of  pus  escaped. 
The  entire  area  of  the  wound  was  then  washed  and  dusted  with  iodoform,  as 
before,  and  a  rubber  drainage  tube,  two  inches  long,  also  dusted  with  iodo- 
form, was  inserted  for  an  inch  of  its  length  into  the  abscess.  The  V-shaped 
flap  was  cut  away  at  its  base,  so  as  to  leave  the  trephine  hole  free  for  drainage. 
In  a  fortnight  after  the  operation,  the  drainage  tube  was  left  out  of  the  wound 
and  the  patient  allowed  to  get  up.  On  the  third  day  after  the  operation  a 
silver  tube  was  substituted  for  the  rubber  tube,  the  latter  not  staying  well  in 
place.  The  optic  neuritis  was  now  greatly  improved  and  disappeared  entirely 
in  about  three  or  four  weeks  after  the  operation. 

In  thirty-eight  days  after  the  trephining  (Nov.  25th),  the  patient  left  the 
hospital  looking  and  feeling  very  well.  There  was  still  some  purulent  dis- 
charge from  the  affected  ear. 


OTOLOGY. 


271 


By  December  4,  a  month  later,  both  wounds  behind  the  ear  had  healed,  and 
there  was  only  a  slight  moisture  in  the  fundus  of  the  right  ear.  There  are 
other  data  contained  in  this  article  most  worthy  of  perusal  by  those  further 
interested  in  such  an  operation. 

On  the  Surgical  Treatment  of  Brain  Suppuration  following 
Ear  Disease. 

In  an  article  with  this  title,  "  the  brain-complications  which,  while  possible 
with  an  intact  membrana  tympani,  are  commonly  associated  with  long-con- 
tinued purulent  discharges  from  the  middle  ear,  with  generally  mastoid  in- 
volvement," are  considered  by  Dr.  K.  F.  Weir,  in  the  New  York  Medical 
Record  of  April  9,  1887.  In  a  case  of  chronic  purulent  disease  of  the  ear,  in 
a  woman,  thirty-nine  years  old,  in  which  the  mastoid  was  operated  on,  the 
subsequent  cerebral  symptoms  pointed  toward  an  abscess  in  the  brain.  There- 
fore, the  original  mastoid  perforation  was  enlarged  for  half  an  inch  (it  had 
been  made  just  where  the  mastoid  glides  into  the  external  canal),  and  deepened, 
until  the  dura  mater  was  exposed  nearly  the  size  of  a  finger  nail.  Cutting 
through  this  membrane,  a  hypodermatic  needle  was  introduced  to  a  depth  of 
nearly  an  inch  and  a  half,  being  directed  along  the  upper  part  of  the  petrous 
bone,  and  also  into  the  cerebral  lobe  in  this  region,  but  nothing  but  a  little 
blood  was  extracted.  No  result  was  obtained  by  this  operation.  Eleven  days 
afterward  the  patient  became  hemiplegic  on  the  side  of  the  affected  ear,  with 
a  temperature  of  103°,  an  irregular  pulse  of  68,  and  there  was  vomiting. 
Under  these  discouraging  circumstances  a  further  ineffectual  attempt  was 
made  to  relieve  the  patient.  With  a  one-inch  trephine  a  button  of  bone  was 
removed  over  the  left  Holanderic  line,  and  the  dura  mater  incised  crucially, 
and  about  two  ounces  of  clear  cerebro-spinal  fluid  were  let  out.  Six  explora- 
tory punctures  were  then  made  with  an  aspirator,  but  nothing  was  detected. 
The  patient  was  not  bettered,  but  died  next  day,  comatose.  An  autopsy  was 
refused. 

Dr.  Weir  states  that  the  situation  of  an  abscess  in  the  brain  depends  to 
some  extent  upon  the  route  by  which  the  inflammation  extends  from  the  ear 
cavities,  "the  condition  of  long-tarrying  pus,  however,  being  by  far  the  most 
important  of  all  factors  in  the  self-infection."  The  important  surgical  fact, 
however,  comes  out  strongly,  from  numerous  observations  of  others,  that  a 
majority  of  the  purulent  depots  in  the  brain  from  ear  disease  are  encountered 
in  the  temporo-sphenoidal  lobe,  and  that  after  this  the  most  affected  locality 
is  the  cerebellum.  It  should  also  be  borne  in  mind  that  both  of  these  regions 
are  fortunately  of  less  value  to  life,  and  can  better  tolerate  surgical  inter- 
ference, than  almost  any  other  portions  of  the  brain.  "  It  is  to  the  fact  of  their 
slight  motor  importance  that  our  power  of  localizing  tumors  and  abscesses  in 
these  regions  is  so  poor,  and  this  consideration  leads  directly  to  the  remark 
that  the  earliest  decided  evidences  of  brain-pressure  in  the  disease  under 
question  should  be  acted  upon  as  soon  as  detected,  since  their  development 
presupposes  an  already  large  accumulation  of  pus."  Surgical  interference 
with  the  brain  is  therefore  advised,  as  soon  as  a  mastoid  operation  has  shown 
itself  to  be  impotent  to  relieve  the  symptoms.  In  this  connection  it  is  wvll 
to  recall  the  fact  that  one-fifth  of  the  cases  of  cerebral  abscess  die  unrelieved 
by  the  mastoid  operation.    The  relief  sometimes  observed  after  a  mastoid 


272 


PKOGRESS  OF  MEDICAL  SCIENCE. 


operation,  either  with  or  without  finding  pus,  is  explained  by  the  supposition 
that  either  the  cerebral  abscess  itself  has  been  drained  by  the  operation,  or, 
what  is  more  likely,  that  an  extra-dural  collection  of  matter  has  been  let  out 
by  the  mastoid  opening.  In  view  of  these  considerations,  Dr.  Weir  believes 
that,  anatomically  and  surgically,  no  reasons  exist  adverse  to  an  early  open- 
ing of  the  dura  and  draining  the  fossa  in  cases  of  suppurative  meningitis  of 
the  middle  fossa  due  to  aural  disease.  When  symptoms  are  present  by  which 
the  probable  site  of  the  purulent  collection  can  be  located,  whether  in  the 
temporo-sphenoidal  lobe  or  in  the  cerebellum,  the  surgeon  will  be  guided 
largely  by  the  neurologist.  The  cerebellar  region  is  not  regarded  as  inacces- 
sible to  surgical  treatment,  and  therefore  the  advice  is  given  that  if  the  cere- 
bral abscess  can  be  excluded  in  favor  of  an  abscess  in  the  cerebellum,  there 
should  be  no  hesitation  in  operating  below  the  tentorium  through  the  occiput. 
The  guide  in  operating  on  the  cerebellum,  given  by  Mr.  Barker,1  should  be 
remembered,  viz.,  to  expose  the  opening  of  the  mastoid  vein,  where,  if  pus 
has  spread  backward  to  the  cerebellum  from  the  ear,  some  of  the  discharge 
will  be  found  oozing  from  beneath  the  dura,  at  this  opening  in  the  masto- 
occipital  region.  Much  of  a  minute  and  specific  nature  is  given  in  this  paper 
by  Dr.  Weir,  and  should  be  carefully  read  by  all  contemplating  an  operation 
for  the  relief  of  an  abscess  in  the  brain. 


DISEASES  OF   THE  LARYNX  AND  CONTIGUOUS 
STRUCTURES. 


UNDER  THE  CHARGE  OF 

J.  SOLIS-COHEN,  M.D., 

PROFESSOR  OF  DISEASES  OF  THE  THROAT  AND  CHEST,  PHILADELPHIA  POLYCLINIC. 

Diphtheria. 

To  favor  syringing  the  nasal  passages,  Reierson,  of  Copenhagen,  passes 
medicated  bougies  which  melt  in  an  hour,  and  reestablish  the  patency  of  the 
passage.  For  large  children  and  adults  they  are  3J  inches  in  length  and  ^th 
of  an  inch  in  diameter.  The  formula  is  cocaine  hydrochlorate  i-^th  grain, 
boric  acid  15  grains,  starch  and  powdered  acacia  each  1 i  grains,  and  glycerine 
sufficient.  For  younger  children  the  bougies  are  shorter,  and  contain  J  grain 
of  the  cocaine,  or  less,  and  10  grains  of  the  boric  acid.  The  bougies  should 
be  stiff,  and  be  pointed  at  one  end.  One  is  introduced  into  each  inferior 
meatus.  They  should  reach  as  far  as  the  nasopharynx. — Journal  of  Laryn- 
gology, Jan.  1887. 

Intubation  of  the  Larynx. 

Dr.  A.  Caille,  of  New  York,  reports  {Medical  Record,  March  19,  1887)  a 
successful  case  in  a  child  five  years  of  age,  with  diphtheritic  laryngeal 


1  Alluded  to  already  in  this  report. 


LARYNGOLOGY. 


273 


stenosis.  Attention  is  called  to  a  Dr.  Denhard's  important  modification  of  the 
gag,  but  this  is  not  described. 

Early  Tracheotomy  in  Diphtheria. 

Mr.  W.  Watson  Cheyne  {Brit.  Med.  Journ.,  March  5, 1887)  believes  that 
the  indication  ought  not  to  be  obstruction  to  the  respiration,  but  that  trache- 
otomy ought  to  be  performed  in  cases  of  diphtheria  as  soon  as  it  is  certain  that 
the  larynx  is  affected ;  and  chiefly  with  the  view  of  preventing  the  spread  of 
the  membrane  downward.  This  he  claims  to  do  by  inspecting  the  incised 
trachea,  removing  any  semblance  of  membrane  if  present,  and,  membrane  or 
no  membrane,  applying  a  1  in  500  solution  of  bichloride  of  mercury. 

Lupus  of  the  Nose  and  Khinoliths. 

Dr.  L.  V.  Silitch,  of  St.  Petersburg  (Vratch,  No.  1,  1887),  reports  two 
instances  of  calculi  removed  from  patients  with  lupus  of  the  nose. 

Mucous  Polypi  in  the  Eight  Antrum. 

Dr.  Shaeffer  (Monatschrift  fur  Ohrenheilhunde,  etc.,  1886,  No.  11)  describes 
an  instance  in  a  female,  fifty-nine  years  of  age,  for  sixteen  years  the  subject 
of  nasal  polypi.  Eight  or  ten  dense,  small  polypi  were  removed  by  scraping 
the  antrum  with  a  sharp  spoon,  access  being  through  the  socket  of  the  second 
molar.  At  the  date  of  the  report  severe  neuralgic  pains,  supraorbital,  infra- 
orbital, and  alveolar,  had  continued  relieved  for  four  months. 

Cyst  of  the  Nasal  Mucous  Membrane. 

Schaeffer  (Monats.f.  Ohrenheil.,  1886,  No.  11)  reports  a  cyst  the  size  of  a 
walnut,  involving  the  anterior  portion  of  the  lower  right  turbinate  body 
and  the  floor  of  the  nose  of  a  woman,  fifty-four  years  of  age.  It  was  opened 
by  a  large  incision  made  upward  behind  the  upper  lip,  and  discharged  a 
tablespoonful  of  albuminous  fluid,  with  a  few  flakes  of  pus.  The  cavity  was 
cauterized  with  chromic  acid,  and  a  drainage  tube  inserted.  Contraction  of 
the  cavity  necessitated  removal  of  the  tube  the  next  day.  Recovery  was  com- 
plete in  eight  days. 

Nasal  and  Nasopharyngeal  Keflex  Neuroses. 

Dr.  P.  McBride,  of  Edinburgh,  in  a  lecture  reported  in  The  British  Medical 
Journal  of  January  29, 1887,  traces  the  recent  history  of  the  literature  on  this 
subject,  coming,  among  other  conclusions,  to  the  following:  That  application 
of  the  actual  cautery  to  the  nasopharyngeal  mucosa  is  no  less  effective  than 
cauterization  of  other  parts  which  has  been  known  to  cure  such  neuroses,  and 
may  be  more  so;  that  we  have  no  means  of  knowing,  in  any  given  case, 
whether  it  can  be  cured  by  treatment  to  the  nose;  that  weakness  of  voice 
accompanying  granular  pharyngitis  may  be  purely  reflex,  and  that  electricity 
to  the  larynx  may  be  indicated  rather  than  destruction  of  the  granulations. 
A  tolerably  complete  bibliographic  index  is  appended. 

NO.  CLXXXVII. — JULY,  1887.  18 


274 


PROGRESS  OF   MEDICAL  SCIENCE. 


Stricture  of  the  (Esophagus. 

In  a  female  forty-nine  years  of  age,  whose  symptoms  had  been  those  of 
chronic  gastritis  with  emesis,  the  oesophagus,  for  nearly  its  entire  length,  was 
found  by  Dr.  J.  W.  Eoosevelt,  dilated  to  about  the  bulk  of  a  quart.  [Medical 
Record,  March  12,  1887.) 

In  an  article  on  the  treatment  of  malignant  stricture  of  the  oesophagus  by 
tubage  or  permanent  catheterism,  by  Mr.  Charter  J.  Symonds  {Brit.  Med. 
Journ.,  April  23,  1887),  he  reports  four  personal  observations,  having  had 
eight  cases  under  prolonged  treatment.  He  prefers  dilatation  with  bougies  so 
long  as  solids  can  be  swallowed ;  then  the  use  of  a  short  rubber  tube,  removed 
from  time  to  time,  until  fluids  can  no  longer  be  taken ;  and  then  resort  to 
Krishaber's  long  tube,  or  to  gastrostomy. 

Pulsating  Arteries  of  the  Pharynx. 

Dr.  J.  W.  Farlow,  of  Boston,  presents  [Journal  Amer.  Med.  Assoc.,  April 
2, 1887)  a  record  of  five  cases  of  large  visible  pulsating  artery  on  the  posterior 
wall  of  the  pharynx,  with  remarks.  All  five  were  in  females,  the  ages  being 
four,  thirteen,  eighteen,  twenty-three,  and  thirty  years. 

Laryngectomy. 

Mr.  Lennox  Browne,  of  London,  has  reported  (Brit.  Med.  Times,  February 
5,  1887)  a  successful  case  of  partial  excision  of  the  larynx,  on  account  of 
intra-laryngeal  epithelioma  in  a  man  sixty-one  years  of  age.  One-half  of 
the  larynx  was  removed. 

Dr.  D.  Hayes  Agnew,  of  Philadelphia,  reports  (Med.  News,  April  9, 1887) 
a  case  of  total  extirpation  for  epithelioma.  Death  ensued  on  the  second  day 
from  exhaustion. 

Extirpation  of  the  larynx  for  carcinoma  was  performed  by  Dr.  J.  H.  Bran- 
ham,  of  Baltimore,  on  January  20th  (Maryland  Med.  Journal,  February  5, 
1887,  p.  356).  Death  ensued  within  thirty-six  hours  from  "  aspirating"  pneu- 
monia. In  this  case,  as  in  Agnew's,  unsuspected  infiltration  of  the  oesopha- 
gus was  revealed  during  the  operation. 

Dr.  W.  Gardner,  of  Aldelaide,  South  Australia,  reports  [Lancet,  May  7, 
1887)  a  case  of  excision  of  the  epitheliomatous  larynx  in  a  male,  aged  sixty. 
Three  months  later  the  disease  had  reappeared. 

Fibrosarcoma  of  the  Nasal  Septum. 

MM.  Calmettes  and  Chatellier  report  [Annales  des  maladies  de  Voreille 
du  larynx,  etc.,  Mars,  1887)  a  case  in  a  married  woman,  thirty  years  of  age, 
successfully  removed  by  operation  with  the  incandescent  electric  loop.  Eleven 
months  later  there  had  been  no  recurrence. 

Black  Tongue, 

Dr.  Ph.  Shech,  of  Munich  [Miinchener  med.  Woch.,  No.  13,  1887),  reports 
a  case  in  which  he  examined  microscopically  a  portion  of  the  product  cut  as 


DEKMATOLOGY. 


275 


close  to  the  base  as  possible.  He  found  it  composed  of  excessively  elongated, 
pigmented,  and  fully  cornified  filiform  papillae,  but  failed  to  find  the  special 
mycophites  described  by  some  observers.  He  concludes  that  the  black  tongue 
belongs  to  the  category  of  hypertrophic,  and  not  of  mycotic,  diseases. 

Pharyngitis  Sicca. 

Dr.  E.  J.  Moure,  of  Bordeaux,  recommends  [Revue  mensuelle  de  laryngologie, 
etc.,  Avril,  1887),  among  other  treatments,  pencillings  with  a  mixture  of 
tincture  of  capsicum,  one  part  in  fifty  to  one  hundred  of  glycerine. 

Laryngeal  Measurements. 

Dr.  Moura,  of  Paris,  concludes  in  the  April  number  of  the,  Revue  mensuelle 
de  laryngologie,  etc.,  his  exhaustive  and  laborious  series  of  measurements  of  the 
various  laryngeal  structures  in  males  and  females  in  his  critical  studies  of  the 
anatomico-physiological  conditions  of  the  human  voice.  A  series  of  tables  pre- 
sents the  statistical  records  of  the  observations  described  at  length  in  the  text. 

Atrophic  Ehinitis. 

Dr.  Noquet,  of  Lille,  in  some  considerations  on  this  theme  [Revue  mens,  de 
lareto,  Mai,  1887),  claims  to  cure  the  disease  in  many  instances,  even  to  regen- 
eration of  the  atrophied  tissues.  He  uses  Weber's  douche  twice  a  day,  with 
a  tablespoonful  of  potassium  chlorate  to  the  litre  of  tepid  water,  followed  by 
pulverization  of  a  solution  composed  of  chloral  hydrate,  1  part ;  boric  acid,  12  ; 
glycerine,  20  ;  distilled  cherry-laurel  water,  40  ;  and  distilled  water,  400  parts. 
In  the  middle  of  the  day  an  additional  pulverization  is  practised  with  water 
aromatized  with  antiseptic  vinegar,  in  the  proportion  of  about  one  to  fifty. 
After  eight  days  carbolic  acid  replaces  the  potassium  chloride,  in  the  propor- 
tion of  about  two  grammes  to  the  litre.  In  addition,  pencillings  are  made  by 
the  attendant  with  a  solution  of  zinc  chloride  (20 : 100?),  rendered  limpid  by 
the  addition  of  a  small  quantity  of  chlorohydric  acid. 


DERMATOLOGY. 


UNDER  THE  CHARGE  OF 

LOUIS  A.  DUHEING,  M.D., 

PROFESSOR  OF  DERMATOLOGY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA. 

AND 

HENEY  W.  STEL WAGON,  M.D., 

PHYSTGIAN  TO  THE  PHILADELPHIA  DISPENSARY  FOR  SKIN  DISEASES. 


Ichthyol. 

Elliot  contributes  {Medical  Record,  March  19,  1887)  a  comprehensive 
paper  on  his  experience  with  ichthyol  in  the  treatment  of  cutaneous  diseases. 
He  finds  that  the  two  ichthyol  preparations — ammonium  ichthyol  and  natrium 


276 


PKOG-RESS  OF   MEDICAL  SCIENCE. 


ichthyol — differ  in  their  action,  often  considerably.  As  a  rule,  better  results 
are  to  be  obtained  by  the  soda  preparation.  In  cases  of  simple  acne,  acute 
or  subacute  in  type,  the  natrium  compound  was  without  result.  It  was  given 
internally  in  doses  of  four  to  eight  grains  three  times  daily ;  the  ammonium 
compound  gave  the  same  negative  results.  In  acne  indurata  the  natrium 
ichthyol  was  also  useless,  but  the  ammonium  preparation  rendered  good 
service.  It  was  applied  as  a  five  to  eight  per  cent,  solution.  Deep-seated, 
indolent,  lumpy  lesions  were  arrested  in  their  development  and  rapidly  disap- 
peared. In  spite  of  its  prolonged  use  and  administration,  however,  new 
lesions  continued  to  make  their  appearance.  It  proved  valuable,  also,  in 
those  cases  of  acne  of  the  chin  in  women,  usually  so  obstinate  to  treatment. 

In  the  treatment  of  rosacea  the  results  were  unsatisfactory.  In  some  cases 
of  eczema  its  local  application  appeared  useful,  but  the  internal  administra- 
tion of  the  remedy  had  no  apparent  effect,  either  on  the  immediate  attack  or 
in  preventing  relapses.  In  chronic  eczema  rubrum,  especially  when  on  the 
legs,  and  depending  upon  varicose  veins,  excellent  results  were  obtained  by 
the  use  of  the  natrium  ichthyol ;  the  ammonium  preparation,  even  in  weak 
percentages,  gave  rise  to  pain,  burning,  and  an  increase  in  the  inflammatory 
symptoms.  More  especially  were  the  favorable  effects  of  the  soda  compound 
(three  to  five  per  cent,  aqueous  solution)  seen  in  its  keratoplastic  action,  in 
this  class  of  cases  associated  with  ulcerations.  In  seborrhoea  oleosa  about  the 
nose,  the  ammonium  compound  gave  good  results,  if  used  alternately  with 
other  plans  of  treatment.  In  intertrigo  the  natrium  ichthyol  proved  service- 
able ;  the  ammonium  salt  was  less  valuable.  It  was  used  in  ointment  form, 
two  to  ten  per  cent,  strength. 

In  dermatitis  these  preparations  were  also  useful.  The  same  good  effects  in 
burns  of  the  first  and  second  degree  were  seen  to  follow  applications  of  a  five 
per  cent,  aqueous  solution  of  the  natrium  salt.  In  chronic  urticaria  the 
administration  of  the  ichthyol  salts  seemed  without  value.  The  same  may 
be  said  as  regards  ichthyosis,  used  both  externally  and  internally.  In  the 
after-treatment  of  lupus,  following  the  use  of  the  nitrate  of  silver  or  the 
curette,  an  ointment  of  the  natrium  compound,  five  per  cent,  strength,  induced 
rapid  healing.  The  effect  of  a  five  per  cent,  ointment  of  the  ammonium 
ichthyol  on  cicatrices  was  of  a  satisfactory  character ;  the  parts  were  rendered 
more  pliable,  and  also  a  decrease  in  size  often  following. 

While  admitting  the  value  of  the  ichthyol  preparations  in  certain  diseases 
of  the  skin,  the  author,  from  his  experience,  cannot  consider  them  entitled 
to  the  therapeutic  importance  claimed  by  Unna,  Kiissner,  and  other  German 
observers. 

Unna,  in  a  brief  note  in  the  British  Medical  Journal  of  April  9,  1887, 
reaffirms  his  opinion  as  to  the  value  of  ichthyol,  administered  internally,  in 
acne  rosacea,  nervous  forms  of  eczema  in  persons  of  nervous  constitution, 
eczema  from  teething,  lichen  urticatus,  erythema  multiforme,  dermatitis 
herpetiformis,  and  furunculosis.  It  is  not  indicated  in  psoriasis.  After  five 
years'  experience  v  ith  the  remedy,  Unna  states  that  it  is  also  valuable  in 
acute  and  chronic  rheumatism,  bronchial  asthma,  chronic  catarrh  of  the 
stomach  and  intestines,  together  with  catarrh  .of  bile  duct  (icterus),  chlorosis, 
tuberculosis  (especially  in  children),  scrofula,  and  in  vascular  engorgements 
of  all  kinds.  [The  dose  of  ichthyol  varies  from  three  to  fifteen  grains  three 
times  daily,  preferably  administered  in  capsules. — Eds.] 


DERMATOLOGY. 


277 


Amenorrhea,  Septicemia,  and  Dermatitis  Multiformis. 

Dr.  H.  F.  Kerr  ( Virginia  Med.  Monthly,  January,  1887)  reports  a  case  of 
amenorrhoea,  followed  by  septicaemia,  a  multiform  dermatitis,  and  death, 
occurring  in  a  previously  healthy  girl  seventeen  years  of  age.  A  cold  was 
contracted,  the  result  of  dancing  and  over-heating,  after  which  menstruation 
ceased,  and  various  general  symptoms  set  in.  Three  months  later,  swelling, 
having  a  purpuric  aspect,  occurred  about  the  face,  hands,  forearms,  and  feet, 
followed  soon  by  numerous  distended  blebs  of  the  size  of  large  split  peas, 
round  and  oval  in  form,  containing  a  clear  fluid.  Intermingled  with  the 
blebs  were  small,  pin-head  sized  pustules,  containing  pus  of  a  whitish  color. 
There  were  itching  and  burning.  In  a  few  days  the  blebs  became  covered 
with  yellowish,  and  later,  brownish  crusts.  The  face  and  forearms  were  the 
seat  of  a  thick,  adherent  mass  of  crusting,  beneath  which  the  skin  showed  an 
oily,  smegma-like,  cheesy  product,  which,  when  removed,  displayed  a  bluish 
sensitive  skin.  In  other  regions,  as  the  neck  and  elbows,  the  crusts  were  soft 
and  fatty,  and  there  existed  deep  and  painful  fissures.  On  the  flexor  surfaces 
of  the  arms,  hands,  and  feet,  especially,  and  to  some  extent  over  the  whole 
surface,  the  skin  had  the  consistence  and  appearance  of  old  leather,  being 
thickened  and  sclerosed.  Later,  desquamation  occurred  in  the  form  of  exfo- 
liation, the  skin  of  the  fingers  and  toes  coming  off  like  casts.  In  certain 
regions,  as  on  the  body  and  the  legs,  the  eruption  manifested  a  squamous 
type.  The  temperature  and  pulse  were  both  above  normal.  The  treatment 
was  expectant.  The  patient  died.  Two  weeks  before  death  a  whitish,  jelly- 
like odorless  discharge  took  place  from  the  vagina.  Previous  to  this,  an 
examination  of  the  uterus  gave  no  cause  for  the  menstrual  suppression. 

Dr.  Kerr  is  of  the  opinion  that  septicaemia  existed  as  the  result  of  suppres- 
sion of  the  menses  and  absorption  of  septic  matter,  and  that  the  cutaneous 
symptoms,  although  different  in  some  respects,  bear  more  relation  to  Duhring's 
dermatitis  herpetiformis  than  to  any  other  disease. 

Impetigo  Herpetiformis. 

Kaposi  {Viertelj.  fur  Derm.  u.  Syph.,  2  Heft,  1  Halfte,  1887)  is  of  the 
opinion  that  the  term  impetigo  herpetiformis,  proposed  and  employed  by 
Hebra,  in  1872,  to  define  a  rare  and  peculiar  disease  of  the  skin,  should  be 
retained  for  this  affection,  of  which  he  has  seen  thirteen  examples.  Hebra's 
observations  led  him  to  think  that  the  disease  was  peculiar  to  women,  and 
who  were  either  pregnant  or  were  in  the  puerperal  state,  a  view  which  has 
likewise  been  entertained  by  Kaposi  until  now.  He  has  recently  seen  a  case 
occurring  in  a  man.  All  of  the  cases,  except  one,  proved  fatal.  The  paper 
is  illustrated  with  four  handsome  chromo-lithographs,  several  of  which  are 
reproductions  from  Hebra's  atlas.  The  author  regards  some  of  the  reported 
cases  of  impetigo  herpetiformis  (as  those  of  Heitzman  and  of  Pataky)  as 
examples  rather  of  pemphigus  and  herpes  iris,  than  of  the  disease  under  con- 
sideration. He  also  takes  exception  to  viewing  impetigo  herpetiformis  as  a 
variety  of  dermatitis  herpetiformis,  as  proposed  by  Duhring. 

Impetigo,  it  is  stated,  signifies  pustules — that  is,  efflorescences  filled  with 
pus;  while  herpetiformis,  as  this  term  was  originally  employed  by  Hebra, 


278 


PROGRESS  OF  MEDICAL  SCIENCE. 


conveys  merely  the  idea  that  the  lesions  are  arranged  as  in  "  herpes  " — that 
is,  in  groups  and  streaks  or  bands  (streifen),  and  that  the  eruption,  just  as 
in  "herpes/'  spreads  peripherally  after  undergoing  central  involution.  It 
would  have  been  better,  perhaps,  the  author  thinks,  to  designate  the  disease 
"impetigo  circinata  et  iris,"  in  which  case  the  term  herpes  would  not  have 
appeared  in  connection  with  this  subject.  Herpes  has  nothing  in  common 
with  impetigo,  the  former  being  denned  as  an  acute  affection  characterized  by 
vesicles  {i.  e.,  efflorescences  rilled  with  clear,  translucent  serum),  which  only 
in  the  course  of  hours  or  days  became  cloudy  or  pustular,  together  with  the 
appearance  of  other  signs  of  involution.  In  impetigo  there  exist  from  the 
beginning  pustular  vesicles  (eiterhaltige  Blaschen),  and  always  only  such  during 
the  entire  course  of  the  disease. 

Impetigo  herpetiformis  is  characterized,  1st,  by  miliary,  existing  primarily  as 
such,  superficial — i.  e.,  epidermoidal — pustules;  2d,  these,  throughout  their 
entire  course,  manifest  the  same  features ;  3d,  they  are  always  arranged  in 
groups  and  aggregations ;  and,  4th,  the  lesions  appear  afresh  on  the  border  of 
older  patches,  in  the  form  of  one  or  more  series,  upon  inflamed  bases,  while 
in  the  centre  involution  occurs,  but  in  no  case  ulceration  and  scarring.  Other 
essential  characters  of  the  disease  are  found  in  the  exclusive  occurrence  in 
pregnant  or  puerperal  women  [the  case  of  the  author,  occurring  in  a  man,  is 
reported  later  in  the  article. — Eds.]  ;  the  accompanying  chills  and  marked 
fever;  preference  of  the  eruption  for  certain  localities,  as  the  genito-crural 
region,  mammae,  and  mucous  membrane  of  the  mouth ;  and  finally,  with  one 
exception,  the  fatal  termination  of  the  disease.  The  author  inclines  to  the 
view  of  the  process  being  pyaemic. 

Two  Epidemics  of  Mollusctjm  Contagiosum. 

Dr.  W.  F.  Mittendorf,  of  New  York  {Trans.  Amer.  Oph.Soe.,  1886),  thinks, 
from  his  observations  in  two  epidemics  of  this  affection,  that  there  is  very 
little  doubt  in  regard  to  its  contagiousness.  The  disease  occurred  in  two  dis- 
tinct homes  for  children  on  Staten  Island.  A  little  girl  was  admitted  to  one 
institution  with  one  or  two  small  "  warts  "  on  the  eyelids :  within  a  few  weeks 
several  of  the  other  girls  had  the  same  growths  appear  on  the  eyelids,  lips, 
and  nose.  Three  months  after  the  admission  of  the  first  case,  twenty-seven 
children,  nearly  all  of  them  girls,  were  affected;  the  lesions  in  every  instance 
involving  the  eyelids,  and  in  some  other  parts  of  the  face,  but  in  no  case  was 
the  rest  of  the  body  invaded. 

In  the  other  institution  the  first  case  was  observed  two  years  ago,  and  at 
date  of  writing,  forty-one  children  were  affected,  as  well  as  one  of  the  nurses 
and  her  child,  who  lived  outside  of  the  nursery.  Some  of  the  children  were 
given  out  to  a  farmer  who  boarded  them.  In  a  short  time  the  disease  had 
spread  to  several  of  the  children  boarding  at  this  farmer's  place,  to  the  child 
of  the  farmer,  and  likewise  to  his  wife,  disfiguring  her  greatly.  In  a  number 
of  instances  the  tumors,  varying  in  size  from  a  mustard  seed  to  that  of  a  pea, 
had  spread  to  other  parts  of  the  face,  but  they  were  usually  confined  to  or 
more  marked  about  the  lids,  some  being  located  at  the  free  edge  of  the  lid 
and  among  the  eyelashes.    Three  cases  of  spontaneous  cure  were  noted. 

In  regard  to  the  treatment,  it  was  found  that  abscission  with  curved  scissors 
and  touching  the  base  with  stick  of  nitrate  of  silver  was  most  satisfactory. 


DERMATOLOGY. 


279 


Merck's  Concentrated  Lactic  Acid  ;  Some  of  its  Uses  in 
Dermatology. 

In  the  Journal  of  Cutaneous  and  Genito- Urinary  Diseases  (April,  1887) 
Knoche  relates  his  experience  with  lactic  acid  in  the  treatment  of  tylosis, 
chloasma,  freckles,  and  warts.  In  tylosis  the  acid  was  applied  pure,  being 
well  rubbed  in.  The  epidermic  masses  were  soon  softened,  and  easily  peeled 
off,  this  result  following  a  few  days'  treatment.  The  affection  tended  to  re- 
cur, but  finally,  under  this  treatment,  disappeared.  In  a  case  of  chloasma, 
the  acid  was  applied  diluted  with  three  parts  of  water ;  after  the  second  appli- 
cation the  surface  became  slightly  inflamed.  The  inflammation  soon  sub- 
sided, and  the  epidermis  began  to  peel  off  in  spots.  Upon  a  repetition  of  the 
treatment  the  discoloration  was  entirely  removed.  A  case  of  freckles  was 
treated  in  the  same  manner  with  satisfactory  results.  In  the  treatment  of 
warts  also  the  author  had  success;  the  free  acid  was  applied,  by  means  of  a 
pointed  stick,  two  or  three  times  daily  for  several  days. 

The  Cutaneous  Punch. 

Keyes  describes  [Journal  of  Cutaneous  and  Genito- Urinary  Diseases,  March, 
1887)  a  small  punch  or  trephine  which  he  has  employed  with  success  in  the 
removal  of  powder  specks  from  the  skin,  in  epithelioma,  moles,  and  other 
blemishes.  The  instrument  is  made  in  several  sizes,  and  has  a  sharp  cutting 
edge.  By  pressing  it  upon  the  skin  and  rapidly  rotating,  a  circular  piece  of 
skin,  corresponding  to  the  size  of  the  instrument  used,  is  cut ;  this  projects, 
and  is  snipped  off  with  the  scissors.  The  depth  of  the  cut  may  be  varied 
according  to  the  amount  of  pressure  made.  As  an  after-dressing  the  author 
used  chiefly  powdered  subsulphate  of  iron.  In  cases  in  which  the  smallest 
sized  punch  was  u?ed  the  scarring  was  scarcely  perceptible. 

Actinomycosis  of  the  Skin. 

Majacchi  {Monatshefte  fur  prak.  Derm.,  No.  7,  1887)  was  the  first  to  describe 
a  case  of  actinomycosis  of  the  skin,  occurring  in  a  young  woman,  in  1882 
(Eivista  clin.  di  Bologna).  A  second  case  is  now  reported  by  this  observer, 
in  the  person  of  a  child,  seven  years  old,  the  disease  being  in  the  neck  in  the 
form  of  two  ulcers  with  scrofulous  aspect.  Between  the  granulations  were 
found  numerous  sulphur-yellow  masses,  some  of  which  were  hard  and  chalky, 
and  could  be  readily  removed  without  pain  or  causing  bleeding.  Microscopic 
examination  showed  a  large  number  of  actinomyces  surrounded  by  young 
granulation  tissue.  Under  the  use  of  mercurial  ointment,  and  later  iodoform, 
the  wounds  healed  in  about  six  weeks,  without  a  return  of  the  disease.  The 
case  observed  in  1882,  manifested  itself  in  an  anthracoid  form  with  purulent 
necrotic  products,  together  with  pyogenic  microorganisms  in  addition  to  the 
actinomyces,  causing  septicaemia  and  the  death  of  the  individual. 

Dermatitis  Venenata. 

Dr.  J.  S.  Howe  (Bost.  Med.  and  Surg.  Journ.,  March  10,  1887)  calls  atten- 
tion to  the  poisonous  effects  upon  the  skin  of  leucanthemum  vulgare,  known 


280 


PKOGKESS  OF  MEDICAL  SCIENCE. 


in  different  localities  as  white  daisy  or  field  daisy,  which  is  plentiful  in  New 
England  and  in  the  middle  Atlantic  States.  Four  cases  of  severe  dermatitis 
are  detailed,  the  eruption  closely  resembling  in  character  that  resulting  from 
rhus,  dogwood,  and  sumach.  It  would  seem  that  the  inflammation  is  parti- 
cularly liable  to  attack  those  who  are  subject  to  dermatitis  from  rhus,  etc. 

Chronic  Zoster. 

Dr.  Letjdet  {Archives  Gen.  de  Med.,  January,  1887)  believes,  with  Verneuil, 
that  zoster  may  present  itself  in  several  forms ;  thus,  it  may  be  acute,  transi- 
tory, and  without  apparent  gravity,  leaving  behind  it  pains  of  longer  or 
shorter  duration,  and  disappearing  without  leaving  trace.  Another  time  the 
eruption  may  persist  over  a  period  of  months,  and  the  ulceration  which  suc- 
ceeds the  vesicles  may  be  deeper,  or,  after  cicatrization  sufficiently  rapid,  the 
scar  may  ulcerate  anew,  and  the  process  repeat  itself  several  times.  Some- 
times it  is  limited  to  the  relapses  of  ulceration.  At  other  times  the  ulceration 
is  accompanied  with  redness,  swelling,  and  a  neuritic  pseudo-phlegmon,  as 
Hamilton  has  described.  Finally,  the  ulceration  may  cicatrize  and  give  place 
to  keloid,  which  may  be  regarded  as  a  truly  chronic  zoster. 

A  second  form  is  that  which  the  author  denominates  "  relapsing  zoster  in 
situ."  A  third  form  is  characterized  by  successive  extension  upon  several 
branches  of  the  same  nerve  or  upon  contiguous  nerves.  Finally,  the  fourth 
form  may  be  called  "  zoster  at  a  distance,"  and  in  these  cases  the  herpetic 
eruption  spreads  out  upon  one  or  another  nerve  distant  or  may  be  secondary 
to  a  lesion  of  a  nerve  filament,  without  apparent  anatomical  relation  to  that 
where  the  eruption  manifests  itself.  This  classification  is  similar  to  that  put 
forth  by  Verneuil,  who  describes  three  forms  of  zoster :  1st.  The  peripheric  or 
centrifugal ;  2d.  The  traumatic  in  proximity ;  3d.  The  traumatic  at  a  distance. 

Leudet's  conclusions  (based  upon  an  experience  of  eighty-five  cases,  extend- 
ing over  thirty  years)  are  summed  up  as  follows : 

1.  Zoster,  in  medical  diseases,  as  in  traumatism,  may  be  :  a,  the  expression 
of  a  local  lesion,  manifesting  itself  upon  the  peripheric  branches  of  an 
altered  nerve ;  or,  b,  it  may  make  its  appearance  at  a  distance  in  general  dis- 
eases, calling  forth  the  lesions  on  the  peripheric  nerves;  or,  c,  it  may  be 
chronic  in  situ,  relapsing  successively  upon  the  nerves  and  branches  in  direct 
anatomical  communication  with  the  primitive  branch  attacked,  or  upon 
distant  branches ;  d,  it  may,  moreover,  be  the  effect  of  poisoning,  as  by  car- 
bonic oxide. 

2.  The  anatomical  cause  is  a  lesion  of  the  intervertebrate  ganglia,  of  the 
Gasserian  ganglion,  and  of  the  peripheric  nerves,  or  of  these  latter  only. 

3.  Local  lesions  of  the  pleura,  of  the  lung,  of  the  spinal  column,  of  the 
spinal  meninges,  of  the  cord,  of  the  brain,  are  such  as  have  occasioned  zoster 
in  the  classical  observations  of  Bserensprung,  Charcot  and  Cottard,  Chandelux, 
and  others.  Chronic  pleurisy  and  tuberculosis  of  the  lung  should  figure 
among  the  most  frequent  causes  of  zoster  (20  out  of  86  cases). 

4.  Chronic  zoster  may  persist  three  or  even  six  months.  The  ulcerations 
which  succeed  the  vesicles  may  reproduce  themselves,  and  sometimes  termi- 
nate in  keloid.  Each  exacerbation  of  the  ulceration  may  be  accompanied 
with  redness  and  swelling. 


MIDWIFERY   AND  GYNECOLOGY. 


281 


5.  Frontal  zoster  may  be  called  forth  by  an  exacerbation  of  pulmonary 
tuberculosis,  and  by  the  paralytic  or  convulsive  accidents  which  have  been 
described  in  empyema. 


MIDWIFERY  AND  GYNECOLOGY. 


UNDER  THE  CHARGE  OF 

D.  Berry  Hart,  M.D.,  F.E.C.P.E., 

LECTURER  ON  MIDWIFERY  AND  DISEASES  OF  WOMEN,  SURGEON'S  HALL,  EDINBURGH,  ETC. 


Complete  Inversion  of  the  Puerperal  Uterus  :  Threatened 
Gangrene,  and  Cure  by  Laparotomy. 

Schmalfuss  records  in  the  Centralbl.  fur  Gynak.,  No.  46,  1886,  a  case  of 
inversion  of  the  uterus  after  labor.  Partial  gangrene  of  the  uterine  wall  was 
present,  and,  therefore,  abdominal  section  was  performed  as  Thomas,  of  New 
York,  has  recommended,  so  that  replacement  might  be  brought  about  with  as 
little  force  as  possible.  With  careful  antiseptic  precautions  the  abdomen  was 
opened  and  the  funnel-shaped  portion  of  the  inverted  uterus  drawn  up.  The 
funnel  was  dilated  with  the  finger  and  pressure  made  through  the  vagina  on 
the  fundus  by  means  of  a  sponge  on  a  sponge-holder.  Eeinversion  was  easily 
performed  in  this  way,  the  uterus  washed  out  with  cold  boracic  lotion,  and  the 
vagina  tamponed  with  iodoform  gauze.    Eecovery  was  complete. 

Defective  Sanitation  as  a  Cause  of  Puerperal  Disease. 

Playfair,  in  the  Lancet  of  Feb.  5,  1887,  draws  attention  to  the  fact  that 
sewer  gas  may  cause  in  puerperal  patients  attacks  of  illness  indistinguishable 
clinically  from  ordinary  puerperal  septicaemia.  The  following  illustrative 
cases  were  given : 

Case  I. — Temperature  104°  for  six  weeks ;  pysemic  abscesses  two  months 
afterward.  The  defects  in  drainage  were  leaking  of  soil  pipe,  leaking  brick 
drains,  and  defective  joints  with  soaking  of  sewage.  Further,  the  lady's  bed- 
room, boudoir,  and  water-closet  were  continuous.  The  curious  fact  is  further 
mentioned  that  in  a  favorite  professional  street  in  London  there  have  been 
seven  cases  of  puerperal  septicaemia,  with  two  deaths,  in  five  years. 

Case  II — Patient  had  dangerous  septic  disease,  while  her  husband  had  also 
diphtheritic  sore  throat.  The  waste  pipe  of  the  bath-room,  which  was  close 
to  the  bed,  opened  directly  into  the  main  drain,  which  was  thus  ventilated 
into  the  dressing-room. 

Case  III. — Lady  had  well-marked  septic  symptoms  in  her  second  confine- 
ment. On  examination  it  was  ultimately  found  that  what  seemed  to  be  a 
wardrobe  in  the  bedroom  was  really  a  water-closet;  it  had  a  special  soil 
pipe  carried  through  the  centre  of  the  house  and  opening  directly  into  the 
main  drain.  It  was  really  a  costly  means  of  ventilating  the  main  drain  into 
the  sleeping  apartment. 

In  all  the  cases  removal  from  the  infected  house  was  followed  by  good 
results. 


282 


PROGRESS  OF   MEDICAL  SCIENCE. 


TREATMENT  IN  CASES  OF  ABORTION  WHERE  THE  PLACENTA  IS  RETAINED. 

Budin,  in  a  recent  lecture  delivered  at  the  Academy  of  Medicine,  considers 
the  treatment  in  cases  of  abortion  where  the  membranes  have  been  retained ; 
the  dangers  of  such  retention  are  hemorrhage  and  septicaemia.  The  ordi- 
narily accepted  treatment  by  immediate  removal,  either  by  the  finger  or 
curette,  he  criticises  unfavorably,  and  then  proceeds  to  discuss 

1.  Is  retention  of  the  placenta  really  a  source  of  frequent  accident  ? 

2.  Are  the  digital  and  instrumental  procedures  for  the  removal  of  the  placenta 
quite  inoffensive  ? 

In  210  cases  at  the  Charite  and  Maternite  the  placenta  was  retained  in 
46  cases  (22  per  cent.).  When  the  abortion  was  complete  the  mortality  was 
almost  nil. 

In  the  incomplete  cases  the  results  were  good ;  one  patient  died  from  septi- 
caemia. Budin  quotes  several  cases  of  death  or  of  cellulitis,  peritonitis,  and 
endometritis  following  active  removal  of  the  placenta,  either  manually  or  by 
the  curette.  He  recommends,  therefore,  the  vaginal  antiseptic  plug  against 
serious  hemorrhage,,  and  vaginal,  or,  if  necessary,  uterine  antiseptic  douches 
when  septic  symptoms  arise.  The  antiseptics  recommended  are  corrosive 
sublimate  1  :  2000  or  1  :  3000,  and  carbolic  acid  2  :  100  or  3  :  100. 

[Budin  is  so  careful  and  accurate  an  observer,  and  one  so  thoroughly  im- 
bued with  the  principles  of  antiseptics,  that  any  recommendation  from  him  is 
worthy  of  all  attention.  At  the  same  time  I  cannot  indorse  his  treatment. 
In  many  cases  of  retained  placenta  after  abortion  I  have  always  removed  the 
retained  portions  at  once  and  douched  the  uterus  with  an  antiseptic.  Where 
the  cervical  canal  has  not  been  sufficiently  dilated  I  have  used  Hegar's  dilator 
to  complete  this.  The  retained  portions  can  thus  be  removed  bimanually  as 
follows :  The  patient  is  chloroformed  and  placed  in  the  dorsal  posture.  The 
right  hand  is  then  passed  into  the  vagina  and  the  index  finger  into  the  uterus, 
which  is  grasped  by  the  left  hand  so  as  to  steady  and  fix  it.  The  finger  can 
now  easily  separate  bulky  remains,  and  any  shreds  can  be  curetted  out.  I 
have  never  had  any  result  but  perfect  recovery,  with  no  inflammatory  sequelae.] 

The  Treatment  of  Umbilical  Hernia. 

Olshausen  believes  {Arch,  fur  Gyncik.,  Bd.  xxix.  Heft  3)  that  umbilical 
hernia  is  fatal  unless  operated  on,  despite  the  statistics  of  Lindfoles,  who  re- 
cords twenty-seven  cases  of  cure  by  pressure  or  the  ligature.  Olshausen,  in 
fifteen  cases,  has  seen  no  instances  of  preservation  of  life  unless  in  operated 
cases.  One  child  with  part  of  the  liver  in  the  sac  lived  five  weeks.  When 
left  to  nature  we  usually  get  destruction  of  the  amnion,  tear  of  the  peritoneum, 
and  peritonitis,  causing  death.    The  following  cases  of  operation  are  given  : 

Case  1  by  Breus.  In  this  case  Breus  opened  the  sac,  replaced  the  hernial 
contents  without  difficulty,  grasped  the  opening  with  forceps,  and  passed 
strong  silk  suture  below  the  forceps.  The  sac  was  then  cut  away  above  the 
forceps  and  cauterized.    Cure  resulted. 

Case  2  by  Felsenreich.  The  sac  was  opened,  excised,  and  the  abdominal  in- 
cision sutured  by  twelve  stitches.    Union  by  first  intention. 

The  cases  of  Lindfoles  and  Stadfeldt  we  omit,  and  pass  on  to  give  the  one 
recorded  by  Olshausen. 


MIDWIFERY  AND  GYNECOLOGY. 


283 


The  child  presented  footling,  weighed  4280  grammes,  and  was  57  cm.  long. 
It  had  a  large  umbilical  hernia  and  macroglossia.  The  cord  was  96  cm.  long, 
and  was  tied  about  10  cm.  from  the  umbilicus.  The  opening  of  the  hernia 
was  about  4  cm.,  and  the  sac  contained  intestine.  Half  an  hour  after  birth 
there  were  bullae  and  a  slight  tear  of  the  sac.  Three  and  a  half  hours  after- 
ward the  following  operation  was  performed  :  An  oval  incision  was  made  close 
to  the  skin  margin  around  the  internal  opening,  and  then  the  skin  edge  and 
amnion  stripped  oif  the  parietal  peritoneum  (sac).  The  raw  edges  of  the  skin 
were  then  brought  together,  the  cut  vessels  being  ligatured.  In  this  way  the 
hernia  was  reduced  with  the  peritoneum  intact.  The  wound  healed  slowly 
but  soundly.  The  child  died  eight  months  afterward  from  intestinal  catarrh. 
On  post-mortem,  the  macroglossia  was  found  to  be  due  to  connective  tissue 
hyperplasia.    There  was  also  non-descent  of  the  ovaries. 

Olshausen  finally  points  out  that  this  operation  cannot  be  practised  unless 
the  hernia  is  replaceable. 

A  Case  of  Gastrotomy  for  Extrauterine  Gestation  in  which  the 
Placenta  never  came  away. 

Dr.  Braithwaite  records  (Land.  Obst.  Trans.,  1886)  a  case  where  he  per- 
formed abdominal  section  for  extrauterine  gestation.  The  foetus  was  full- 
grown,  had  been  dead  for  three  weeks,  and  was  lying  quite  free  in  the  abdomi- 
nal cavity,  except  that  a  fine  membrane  cut  it  off  from  the  intestines  which 
lay  above  it.  The  placenta  covered  the  top  of  the  uterus,  was  not  removed, 
and,  so  far  as  could  be  made  out,  did  not  come  away  afterward.  When  the 
patient  was  examined  bimanually  some  time  after  the  operation,  no  trace  of 
it  could  be  felt,  unless  as  a  small  ring  of  dense  tissue  at  the  level  of  about  half 
an  inch  from  the  fundus  uteri. 

Foztus  and  Placenta  of  Extrauterine  Gestation  removed  by 
Abdominal  Section. 

Dr.  Herman  describes  (Lond.  Obst.  Trans.,  1886)  a  case  where  he  removed 
an  extrauterine  foetus  by  abdominal  section.  The  foetus  lay  enclosed  and 
adherent  to  its  membranes,  the  liquor  amnii  having  been  absorbed.  The 
placenta  was  attached  to  the  anterior  abdominal  wall,  upper  surface  of 
bladder,  and  left  broad  ligament.  Dr.  Herman  tied  and  divided  muscular 
adhesions  between  placenta  and  omentum,  and  separated,  by  tearing,  the 
placenta  from  the  bladder  and  abdominal  wall.  The  part  of  the  placenta 
adherent  to  the  broad  ligament  was  treated  by  tying  the  latter  in  two  parts, 
and  then  cutting  away  the  placenta.  In  this  way  the  ovary  had  to  be 
removed. 

The  foetus  weighed  3  pounds  8  ounces,  and  was  compressed  and  flattened. 
The  weight  of  the  placenta  was  28]  ounces ;  the  cord  was  shrivelled,  and 
the  placenta  seemed  made  up  of  placental  tissue  with  extravasated  blood 
between  the  tufts. 

A  Case  of  Eemoval  of  both  Ovaries  during  Pregnax<  y. 

Mr.  Knowsley  Thornton  {Lond.  Obst.  Trans.)  records  a  case  where  he 
removed  both  ovaries  at  the  fourth  month  of  pregnancy.    The  operation  was 


284 


PROGRESS  OF   MEDICAL  SCIENCE. 


performed  in  the  usual  manner,  the  ligatures  being  placed  on  the  pedicles  as 
far  from  the  uterus  as  possible.  This  was  done  with  the  intention  of  avoiding 
the  metrostaxis  which  usually  comes  on  when  both  ovaries  and  tubes  are 
removed,  as  it  might  hence  set  up  abortion. 

The  patient  recovered,  and  was  delivered  at  the  eighth  month  of  gestation 
of  a  healthy  child  ;  the  third  stage  was  normal.  Lactation  was  performed 
satisfactorily,  although  the  uterus  was  atrophic  four  months  afterward,  aud 
the  mother  had  the  usual  menopause  phenomena.  The  case  further  shows 
that  the  ovaries  can  have  no  influence  in  starting  labor. 

On  Mercurialism  in  Lying-in  Women  undergoing  Sublimate 

Irrigation. 

Dakin,  in  the  Lond.  Obst.  Trans.,  1886,  makes  a  valuable  contribution  to 
the  question  of  mercurialism  following  the  use  of  corrosive  sublimate  as  an 
antiseptic.  As  is  now  well  known,  Tarnier,  in  1882,  was  the  first  to  use  this 
drug  as  an  antiseptic  in  puerperal  cases.  The  general  outcome  of  its  use  has 
been  a  great  diminution  in  the  mortality  and  morbility  of  maternities,  a 
result  somewhat  clouded  by  occasional  cases  of  poisoning  with  even  fatal 
results,  as  many  as  eight  deaths  having  been  reported.  The  cases  known  are 
as  follows  : 

1.  Stadtfeldfs  case.  One  intrauterine  injection,  1 : 1500,  five  days  after  labor. 
Death  on  eleventh  day.    Kidney  and  intestinal  changes  found. 

2.  Somer's  case.    Vaginal,  1 :  1000. 

3.  Winter's  case.  Intrauterine  douche,  1 : 1000 ;  vaginal  afterward  of 
1 : 1000.  Death  on  fourth  day.  Post-mortem,  gangrenous  colitis  and  peri- 
toneal exudation. 

4.  Vdhtz.  Intrauterine  injection,  1 :  750,  after  abortion.  Death  on  eleventh 
day  after  intestinal  and  kidney  symptoms. 

5.  Partridge.  Two  intrauterine  injections,  1:2000;  dysenteric  symptoms 
and  death. 

6  and  7.  Thorn.  Intrauterine  douche  after  missed  abortion,  1 : 1000  ;  vaginal 
douche,  1 : 1000  in  forceps  case.    Eenal  and  intestinal  lesions. 

8.  ZiegenspecJc.  Death  on  thirteenth  day  after  three  injections  of  1 :  5000. 
No  bad  symptoms  until  second  intrauterine  douche  on  eighth  day ;  patient 
died  five  days  afterward. 

9.  Netzel.  Intrauterine  douche,  1 : 1500,  on  seventh  day ;  abdominal  pain 
then  complained  of ;  renal  symptoms  with  albumen  and  lime  salts  in  urine. 
Death  on  twenty-second  day. 

10.  Grustav  Braun.  Douche  during  first  stage ;  episiotomy  performed  during 
second  stage,  and  intrauterine  irrigation,  1 : 1000,  after  expulsion  of  placenta. 
Diarrhoea  on  third,  and  collapse  on  seventh  day. 

11.  Hofmeier.    One  douche  of  1 : 1000.    Death  on  sixth  day. 

In  all  cases  of  douching  Keller  found  mercury  in  urine,  and  also  albumen. 

Dakin  then  gives  the  results  of  the  use  of  sublimate  irrigation  in  170 
patients  confined  in  the  General  Lying-in  Hospital,  London,  under  the 
charge  of  Dr.  William  P.  Champneys.  The  sublimate  is  used  as  follows: 
Hands  and  instruments  are  disinfected  with  1 : 1000  ;  the  vagina  is  douched 
after  labor  with  1 :  2000,  two  pints,  at  a  temperature  of  115°-120°  F.,  being 


MIDWIFERY   AND  GYNECOLOGY. 


285 


used.  For  the  first  two  days  three  pints  of  1 :  2000  at  110°  F.  are  employed, 
and  then  the  strength  is  reduced  to  1 :  4000.  The  patient  occupies  the  dorsal 
posture,  and  after  the  douche  is  finished  turns  on  her  hands  and  knees,  to 
evacuate  any  residuum. 

Symptoms  of  poisoning  usually  appeared  between  the  fourth  and  seventh 
days,  and  were  usually  diarrhoea,  with  blood  and  tenesmus,  sometimes  vom- 
iting, patchy  tongue,  thirst  and  loss  of  appetite,  fetor  of  breath,  salivation 
with  tenderness  of  teeth  and  gums,  as  well  as  red  line  on  gums.  The  urine 
contained  albumen  in  11  of  the  cases. 

Details  of  the  one  fatal  case  are  given,  with  examination  of  kidneys. 

He  comes  to  the  conclusion  that  a  strength  of  1 : 4000  is  sufficient  for 
douching. 

Castration  in  Neuroses. 

Schroder  (Zeitschrift  fur  Oeb.  und  Gynalc.,  Bd.  xiii.  Hft.  2)  first  points 
out  that  his  disagreement  with  the  views  of  Hegar  in  this  question  is  only 
partial.  With  Hegar,  he  agrees  in  separating  the  cases  where  one  removes 
diseased  ovaries  from  those  where  the  ovaries  are  removed  to  bring  on  the 
menopause.  In  the  first  class  of  cases  the  indications  present  no  difficulty. 
No  one  can  dispute  that  it  is  right  to  remove  ovaries  when  diseased.  The 
only  point  on  which  opinions  can  differ  is  as  to  whether  the  disease  is  severe 
enough  to  demand  extirpation.  This  class,  of  course,  includes  ordinary 
ovariotomies,  but  one  has  as  much  right  to  remove  a  chronically  inflamed 
ovary  when  dangerous  to  life  or  causing  pelvic  inflammatory  mischief.  When 
one  ovary  is  thus  affected,  it, alone  should  be  removed;  and  it  may  be  possible 
to  remove  only  part  of  it.  Schroder  would,  with  Martin,  include  these  with 
ovariotomy  cases,  thus  separating  them  from  castration. 

The  second  class  is  quite  different,  as  one  must  remove  both  ovaries  com- 
pletely; not  because  they  are  diseased,  but  to  bring  on  the  menopause. 
Schroder  further  points  out  that  the  effect  of  the  removal  of  the  ovaries  or 
fibroids  must  be  settled  by  experience,  and  criticises  the  view  that  neuroses 
are  associated  with  pathological  changes  in  the  ovaries.  Hegar  admits  that 
the  nervous  disturbance  does  not  in  any  way  agree  with  the  severity  of  the 
pathological  changes,  but  Schroder  goes  further,  and  alleges  that  the  hitherto 
demonstrated  changes,  either  clinical  or  anatomical,  have  nothing  to  do  with 
general  neuroses. 

Schroder  next  points  out  the  difficulty  of  diagnosticating  minor  changes  in  the 
ovaries,  even  with  Schultze's  method,  and  alleges  (quite  truly)  that  our  knowl- 
edge of  the  pathological  anatomy  of  the  ovary,  apart  from  tumor  formation, 
is  practically  a  blank,  and  that  there  is,  therefore,  entirely  wanting  a  scien- 
tific basis  for  castration  so  far  as  the  pathological  changes  in  the  ovary  are 
concerned.  Schroder  has  performed  castration  for  neuroses  ten  times,  but 
gives  the  result  in  only  four,  where  the  time  since  operation  has  been  long 
enough  to  enable  one  to  judge.  He  points  out  here  that  the  immediate  effect 
may  be  good,  but  that  ultimately  a  relapse  to  the  old  condition  takes  place. 
The  results  in  the  four  cases  were  good;  no  special  pathological  changes  were 
found  in  the  ovaries  removed. 


286 


PROGRESS  OF   MEDICAL  SCIENCE. 


A  Case  of  Cured  Peritoneal  Tuberculosis. 

Potest  (Centr.  fur  Gynalc.,  Jan.  15,  1887)  first  draws  attention  to  Hegar's 
monograph  on  genital  tuberculosis,  and  to  the  statements  in  it  as  to  the  cure 
or  arrest  of  diffuse  miliary  tubercle  of  the  peritoneum  by  laparotomy.  He 
points  out  that  it  must  be  shown  in  each  case  that  the  affection  is  really 
miliary  tubercle,  and  not  a  granulating  affection  of  some  other  sort.  This 
can  only  be  settled,  of  course,  by  the  discovery  of  miliary  tubercle  and  the 
bacillus  tuberculosis  on  microscopic  examination. 

Konig,  in  some  cases  of  peritoneal  tuberculosis,  treated  with  carbolic  acid 
and  iodoform,  found  miliary  tubercle  present  on  microscopic  examination ; 
but  there  is  no  information  as  to  the  presence  of  bacilli.  Poten  then  records 
a  case  of  peritoneal  tuberculosis  in  a  woman  where  bacilli  were  found.  Frau 
K.,  twenty-nine  years  of  age,  had  three  children,  the  last  a  year  and  a  half 
before.  During  the  suckling  of  her  youngest  child  had  swollen  limbs,  which 
continued  after  weaning.  Afterward  swelling  of  the  abdomen  began,  and 
also  some  prolapsus  uteri.    Weakness  and  wasting  were  also  present. 

On  examination  the  abdomen  was  found  markedly  swollen,  especially  at 
and  below  the  umbilicus.  The  abdominal  walls  were  somewhat  stretched, 
soft,  and  could  be  indented.  Fluctuation  was  distinct,  but  there  was  no 
special  hardness.  On  percussion  the  note  was  markedly  tympanitic  below  the 
liver,  dull  between  the  symphysis  and  a  point  a  hand's  breadth  above  the 
umbilicus,  as  well  as  in  the  flanks  and  on  change  of  position. 

The  anterior  vaginal  wall  was  slightly  prolapsed,  the  uterus  retroposed, 
movable,  and  with  no  evident  tumor  attachment.  Fluctuation  in  Douglas's 
pouch  doubtful  per  rectum.    Diagnosis  was  thus  difficult. 

On  abdominal  section  clear  yellow  fluid  issued  in  a  stream  from  the  incision. 
The  peritoneum  and  intestines  were  then  seen  to  be  covered  with  small 
nodules  of  a  grayish-red  color ;  uterus  and  ovaries  unaltered  in  size,  but  also 
covered  with  nodules.  All  the  fluid  was  removed,  a  piece  of  the  peritoneum 
resected  for  microscopic  examination,  and  the  incision  closed. 

The  patient  recovered  perfectly  so  far  as  the  operation  was  concerned,  and 
was,  a  year  after  the  operation,  in  good  health,  with  no  tubercular  affection 
apparent. 

The  piece  of  peritoneum  removed  was  2-3  mm.  thick,  and  dense  in  consist- 
ence. On  section  it  was  grayish-red  in  color,  with  yellow  specks.  The  free 
surface  showed  little  prominences  about  the  size  of  a  millet-seed,  and  without 
ulceration ;  the  sheen  of  the  peritoneum  was  lost.  In  section  perpendicular 
to  the  surface,  one  could  see  a  cellular  granulation  tissue,  which  seemed 
toward  the  surface  more  like  connective  tissue.  Tubercles,  single  and  in 
groups,  were  present,  and  most  abundant  in  the  deeper  layers  of  the  thickened 
peritoneum ;  they  form  the  miliary  prominences  at  the  surface  already  alluded 
to.  They  show  the  most  varied  forms,  from  simple  granulation  knots  to  de- 
veloped wandering  tubercle  cells,  with  central  caseation.  Abundant  fat  cells 
lie  near  the  tubercles  and  in  the  loose  subserous  tissue. 

The  demonstration  of  the  bacilli  was  attended  with  difficulty.  In  many  of 
the  sections  no  bacilli  could  be  found,  but  ultimately  they  were  found,  though 
sparingly,  in  some  of  the  wandering  cells.  They  were  usually  single,  but  in 
one  cell  two  were  noted. 


MIDWIFERY   AND  GYNECOLOGY. 


287 


On  Periuterine  Hematocele. 

Gusserow  points  out  (Arch,  far  Gyndk.,  Bd.  29,  Heft  3)  that  of  late  years 
our  knowledge  in  regard  to  hematocele  has  been  increased  by  Kuhn,  who 
showed  that  we  could  have  extraperitoneal  hematocele  apart  from  the  puer- 
perium;  by  Gallam,  who  as  early  as. 1855  pointed  out  that  the  greater  number 
of  hematoceles  were  due  to  burst  tubal  pregnancies;  and  finally,  in  regard 
to  treatment,  by  the  clinical  work  of  Zweifel,  Martin,  and  others. 

Gusserow  then  takes  up  the  consideration  of  eight  cases  of  retrouterine 
hematocele  on  which  he  operated. 

Case  I.  Frau  E.,  thirty-six  years  of  age,  first  menstruated  when  sixteen. 
The  period  was  regular,  and  lasted  two  days ;  her  last  period  was  on  Septem- 
ber 11,  1885.  She  has  had  five  children,  the  last  in  1876.  After  an  abortion 
in  1878  she  had  pelvic  inflammation,  which  kept  her  in  bed  for  six  weeks. 
On  March  1,  1885,  bleeding  came  on,  which  lasted  till  November  7.  Great 
abdominal  pains  came  on  then,  especially  at  the  right  side,  but  diminished 
after  a  practitioner  removed  some  membranous  shreds.  The  pains,  however, 
continued.  On  the  19th  she  had  severe  attacks  when  the  bowels  or  bladder 
acted,  and  therefore  sought  admission  to  hospital  on  the  29th. 

On  abdominal  palpation,  the  abdomen  was  soft  and  painful  in  both  iliac 
regions.  Through  the  abdominal  wall  one  could  feel  a  tumor  on  the  right 
lower  regions,  with  an  upper  convex  border  reaching  as  high  up  on  the  right 
as  the  anterior  superior  spine  and  navel.  It  did  not  reach  as  high  in  the 
middle  line.  The  posterior  fornix  was  bulged  with  an  elastic  tumor  and  the 
cervix  pushed  forward  to  the  symphysis.  The  tumor  could  be  felt  on  both 
sides  of  the  uterus. 

Diagnosis.  Retrouterine  hematocele.  The  pains  increased,  but  there  was 
no  fever ;  the  abdomen  became  tympanitic,  and  there  was  great  difficulty  in 
evacuating  the  bowels  and  bladder;  while  the  tumor  did  not  increase  for  three 
weeks,  neither  did  it  diminish.  The  posterior  fornix  was  therefore  incised, 
the  patient  being  chloroformed,  and  a  large  quantity  of  black,  broken- 
down  blood,  as  well  as  fresh  and  old  clots,  washed  out  with  salicylic  acid.  A 
drainage  tube  was  then  inserted,  and  the  vagina  packed  with  iodoform  gauze. 
The  patient  improved  decidedly  after  this,  and  the  tumor  diminished  to  the 
size  of  a  child's  head. 

On  December  26  the  catheter  for  washing  out  passed  toward  the  right  into 
a  compartment  of  the  tumor,  and  evacuated  400  to  500  c.  cm.  of  a  dirty  fluid, 
which  clotted  in  part  on  exposure,  contained  much  albumen,  and  red  and 
white  blood-corpuscles.  The  patient  continued  well  till  January  11,  when 
the  swelling  again  filled,  and  severe  pains  came  on ;  menstruation  was  not 
present.  Pulse  100°,  temperature  38.2°  C.  By  injection  a  considerable 
amount  of  fluid  was  evacuated  on  the  15th,  but  the  patient's  condition  did 
not  improve  on  the  28th.  Abdominal  section  was  performed,  and  the  cyst* 
like  walls  of  the  sac  stitched  to  the  abdominal  walls.  A  drainage  tube  could 
then  be  passed,  and  all  secretion  drained  through  the  vagina.  The  patient 
improved  until  July  3,  when  she  had  all  the  symptoms  and  signs  of  perforative 
peritonitis,  viz.,  distention,  sickness,  almost  imperceptible  pulse,  etc.  All  this 
passed  off  under  the  free  use  of  stimulants.  Patient  was  practically  well  on 
March  4. 


288 


PKOGKESS  OF   MEDICAL  SCIENCE. 


Case  II  Frau  D.,  thirty-seven  years  of  age.  Had  nine  children;  an  abor- 
tion in  1882,  followed  by  pelvic  inflammation.  On  December  18,  1885,  had 
severe  pain  in  abdomen,  with  uterine  hemorrhage ;  on  January  6  a  tumor 
was  felt  through  the  left  lateral  fornix  and  in  Douglas's  pouch.  Its  upper 
boundary  was  above  the  pubis,  and  the  uterus  was  to  the  front,  though  still 
retroflexed.    Temperature  normal. 

The  tumor  was  incised  per  vaginam,  and  the  finger  passed  into  the  loose 
cedematous  connective  tissue.  A  considerable  amount  of  dark  blood  was  thus 
evacuated,  and  old  blood  clots  removed  with  a  blunt  curette.  No  evidence  of 
extrauterine  pregnancy  could  be  found.  The  edges  of  the  sac  were  sutured 
to  the  vaginal  incision,  and  the  cavity  packed  with  loose  iodoform  gauze. 
The  gauze  was  removed  in  a  few  hours,  and  a  drainage  tube  passed.  Eecovery 
good.  Douglas's  pouch  free,  uterus  retroflexed  and  fixed  somewhat  to  the 
right  side.  The  other  five  cases  are  much  like  the  preceding  in  their  history, 
physical  signs,  and  treatment.    All  the  eight  recovered. 

The  critical  remarks  given  on  these  cases  are  as  follows :  Gusserow  believes 
his  cases  to  have  been  hsematomata — i.  e.,  extraperitoneal  effusions  of  blood. 
Case  II.  he  believes  to  have  been  hematoma  of  the  left  broad  ligament.  In 
regard  to  the  diagnosis  of  the  hsematoma  of  the  broad  ligament,  he  asserts 
that  the  important  points  are  that  the  upper  half  cylindrical  boundary  can 
be  felt  while  handling  any  tumor  case — he  felt  it  in  Douglas's  pouch.  The 
lateral  position  of  the  tumor,  and  its  mobility  at  first,  are  also  valuable  in 
pointing  to  this  diagnosis.  The  remaining  finger  can  be  passed  behind  and 
in  front  of  the  swelling,  but  notes  its  lateral  continuity  with  the  uterus  and 
pelvic  wall. 

In  four  of  his  cases  Gusserow  suspected  extrauterine  pregnancy  as  the  cause 
of  the  effusion,  but  found  no  evidence  of  this  in  the  blood  evacuated.  He 
points  out  that  there  need  be  no  fear  of  septic  infection  by  this  operative  in- 
terference and  that  by  it  pains,  etc.,  are  immediately  removed  and  the  patient 
cured  in  a  period  varying  from  twelve  days  to  three  weeks.  The  details  are 
as  follows :  Case  1,  cured  in  three  weeks ;  Case  2,  in  three  weeks  ;  Case  3,  in 
twelve  days ;  Case  4,  in  eighteen  days,  etc. 

The  following  was  the  method  of  opening  the  blood  effusion.  The  vagina 
was  first  douched  with  corrosive  sublimate  solution  1 : 2000,  and  then  the 
lowest  point  of  the  tumor  punctured  with  a  lancet-shaped  knife,  the  incision 
being  enlarged  as  required.  The  clots  were  then  washed  out  with  salicylic 
acid  solutions  and  the  walls  of  the  cyst,  when  distinguishable,  stitched  to  the 
vaginal  mucous  membrane.  A  thick  drainage  tube  was  inserted  and  the 
vagina  tamponed  with  iodoform  gauze. 

Gusserow  considers  this  method  superior  to  treatment  by  laparotomy.  He 
recommends  operative  treatment  only  in  cases  where  absorption  of  the  blood 
is  delayed  or  where  the  local  manifestations  are  severe..  The  majority  of 
cases  of  periuterine  hematocele  are  cured  with  rest  in  bed. 

On  Cancer  of  the  Uterus. 

Williams,  in  his  interesting  Harveian  lectures  (lancet,  1887),  defines  the 
term  "cancer  of  the  uterus"  as  meaning  a  new  growth  possessing  malignant 
properties — i.  e.,  it  possesses  the  power  of  invading  neighboring  tissues  and  of 


MIDWIFERY   AND  GYNECOLOGY. 


289 


reproducing  itself  in  the  form  of  secondary  growths  in  other  and  distant  parts. 
He  recognizes  three  types  of  malignant  disease,  viz.,  sarcoma,  adenoma,  and 
carcinoma.  Sarcoma  is  of  the  connective  tissue  type.  Carcinoma  and  ade- 
noma are  of  the  epithelial  type.  This  classification  is  not  perfect,  of  course, 
as  we  may  have  what  looks  like  a  mixed  form,  and  sarcoma  may  assume  an 
alveolar  form  like  adenoma. 

The  uterus  is  considered  as  divided  into  three  parts,  viz.,  the  vaginal  por- 
tion, the  cervix,  and  the  body.  The  portio  lies  projecting  into  the  vagina; 
the  cervix  is  bounded  below  by  this  and  above  by  a  plane  passing  through 
the  portion  where  the  characteristic  cervical  structure  ends  and  the  tubular 
glands  of  the  uterus  begin.  This,  of  course,  gives  also  the  lower  boundary  of 
the  body.  Dr.  Williams  condemns  rightly  the  use  of  the  terms  scirrhus,  en- 
cephaloid,  medullary,  and  epithelioma. 

Cancer  of  the  portia  vaginalis  is  defined  as  beginning  in  the  stratified  epithe- 
lium on  the  vaginal  surface  or  in  the  transitional  epithelium  at  the  os  exter- 
num. He  thus  excludes  sarcomata  and  glandular  cancer.  Eight  cases  are 
described  in  their  clinical  features  and  the  microscopic  examination  of  the 
parts  removed  given.  The  disease  was  found  to  begin  atone  or  several  points, 
not  to  spread  into  the  cervical  canal  but  to  creep  toward  the  vaginal  wall, 
thus  advancing  superficially  in  seven  of  the  cases.  Seven  of  the  cases  were 
married,  but  they  had  less  than  the  average  number  of  children.  The  earliest 
symptom  was  hemorrhage. 

Before  taking  up  cervical  cancer,  the  nature  of  the  so-called  erosion  is  con- 
sidered. A  true  erosion  is  defined  as  being  a  surface  with  a  structure  like 
that  of  the  mucous  membrane  of  the  cervical  canal  lying  in  the  position  usu- 
ally occupied  by  squamous-  epithelium.  It  differs  from  cancer  in  that  its 
epithelium  is  in  single  layer,  and  from  adenoma  in  the  glands  being  compara- 
tively superficial.  He  believes  such  erosions  to  be  produced  by  the  glandular 
epithelium  proliferating  and  then  destroying  and  replacing  the  squamous 
epithelium  beneath  which  they  lie.  The  stroma  around  the  glands  is  also 
active,  being  infiltrated  with  nuclei  and  small  cells.  The  view  advanced 
differs  from  that  of  Ruge  and  Veit,  who  hold  that  the  glands  in  an  erosion 
arise  from  a  change  in  the  deeper  layer  of  the  stratified  epithelium. 

Cancer  of  the  cervix  begins  in  the  glands,  which  increase  in  number  and 
grow  where  usually  they  do  not  exist.  Their  epithelial  lining  proliferates, 
becomes  multiple-layered,  and  may  fill  the  gland  lumen.  .  It  may  exist  in  a 
polypoid,  papillary,  or  nodular  form ;  the  two  latter  forms  passing  into  the 
substance  of  the  cervix  and  connective  tissue  around  it — the  very  worst  direc- 
tion possible  from  an  operative  point  of  view.  They  avoid  encroachment  on 
the  uterine  body  and  vaginal  walls. 

Cancer  of  the  body  of  the  uterus  is  either  adenoma  or  true  cancer,  both 
growing  from  the  gland  epithelium.  It  spreads  into  the  muscular  coat  and 
may  open  into  the  intestine,  or  cause  inflammatory  adhesions.  The  glands 
affected  are  those  of  the  broad  ligament  or  of  the  connective  tissue  anterior  to 
the  spinal  column.  In  all  the  cases  the  disease  begins  after  the  menopause, 
the  ages  averaging  from  fifty-three  to  sixty-three. 

Dr.  Williams  discusses  finally  the  question  of  radical  treatment,  and  advo- 
cates supravaginal  amputation  for  cervical  cancer  as  against  total  extirpation. 
For  cancer  of  the  body,  of  course,  total  extirpation  is  the  only  remedy. 

NO.  CLXXXVII. — JULY,  1887.  19 


290 


PROGKESS  OF   MEDICAL  SCIENCE. 


The  Etiology,  Pathology,  and  Classification  of  Salpingitis. 

The  question  of  the  pathology  of  salpingitis  has  been  a  matter  of  controversy 
between  Tait,  of  Birmingham,  and  Sanger,  of  Leipzig.  We  have  no  intention 
of  judging  between  the  two  combatants,  but  merely  summarize  the  excellent 
resume  of  the  classification  and  pathology  of  salpingitis  given  by  Sanger  in  a 
letter  addressed  to  the  President  of  the  Chicago  Gynecological  Society  (Amer. 
Journ.  of  Obstetrics,  March,  1887). 

Sanger  bases  his  pathology  on  the  germ  theory  and  the  anatomical  relations 
of  the  sexual  organs.  The  genital  tract  from  hymen  to  frimbriated  end  of 
Fallopian  tube  is  exposed  to  access  by  organisms  which  may  pass  from  the  ex- 
ternal medium  to  the  tubes  either  along  the  mucous  membrane  or  through  the 
lymphatics ;  mischief  may  also  pass  from  the  peritoneal  cavity  into  the  tubes. 

Various  microorganisms  have  been  found  in  the  genital  tract,  but  those 
considered  the  cause  of  disease  (pathogenous  microorganisms)  are  not  many. 
Sanger  classifies  the  forms  of  salpingitis  into  three  groups,  as  follows : 

Group  I.    Forms  of  salpingitis  produced  by  known  specific  miwobes. 

1.  Salpingitis  gonorrhceica,  produced  by  the  gonococcus  of  Neisser. 

2.  Salpingitis  tuberculosa,  produced  by  the  bacillus  tuberculosis  of  Koch. 

3.  Salpingitis  actinomycotica,  produced  by  the  actinomyces  bovis  of 
Ballinger. 

Group  II.    Forms  of  salpingitis  due  to  specific  microbes  identical  with  those 
producing  traumatic  infection. 
1.  Salpingitis  septica. 

Group  III.  Forms  of  salpingitis  produced  by  specific  but  as  yet  unknown 
microbes. 

1.  Salpingitis  syphilitica. 

Group  I.  Gonorrhoea!  salpingitis  is  admitted  by  all  as  a  form,  the  only 
point  denied  by  some  being  whether  the  gonococcus  of  Neisser  is  the  cause 
of  it.  All  admit  that  gonorrhoea  spreads  to  the  tubes  and  sets  up  this  form. 
Sanger  shows  that  the  tube  becomes  distended  with  pus,  chiefly  at  the  abdom- 
inal end,  while  the  uterine  end  becomes  thickened ;  the  peritoneum  becomes 
infected  by  the  pus  escaping  through  the  ostium  abdominale.  Gonorrhoea 
produces  only  surface  suppuration,  and  any  abscesses  in  the  psoas  ligament  or 
ovaries  are  usually  septic. 

It  must  not  be  forgotten  that  while  Neisser  s  gonococci  are  found  abun- 
dantly in  the  gonorrhoeal  pus  from  the  cervix,  their  demonstration  in  the 
tubes  is  difficult,  and  in  some  cases  of  undoubted  gonorrhoeal  salpingitis  they 
have  not  been  found. 

Salpingitis  tuberculosa  is  known  chiefly  through  Hegar's  work  (Amer. 
Journ.  Med.  Sci.  for  April,  1887,  p.  586),  and  is  a  distinct  affection  from  the 
caseating  pus  of  a  pyosalpinx.  This  latter  should  be  termed  "  coagulation 
necrosis." 

Salpingitis  actinomycotica  is  undoubtedly  one  of  the  greatest  rarities  in 
gynecology,  but  has  been  described  by  Zemann  in  his  paper  "  Ueber  die  Akti- 
nomycose  des  Bauchfills  und  der  Baucheingeweide  beim  Menschen."  In  this 
case  the  tubes  were  dilated  and  purulent,  with  clumps  of  actinomyces  present 
in  the  lumen  of  the  tube  and  granulations  in  the  walls.  The  fungus  had 
passed  from  the  intestines  or  vagina.  [Descriptions  of  this  fungus  will  be 
found  in  Klein's  Microorganisms  and  Woodhead's  Pathology.] 


MEDICAL  JUEISPKUDENCE   AND  TOXICOLOGY. 


291 


In  the  forms  of  salpingitis  known  as  septica  and  syphilitica  the  evidence  of 
their  being  due  to  a  pathogenic  microorganism  is  not  yet  complete.  It  must 
be  remembered  that  the  pathogenous  microorganism  of  syphilis  has  not  yet 
been  discovered,  and  much  has  yet  to  be  done  in  regard  to  those  and  septic 
conditions. 

The  Pathology  of  Chronic  Inflammatory  Disease  of  the  Uterine 
Appendages  as  Illustrated  by  the  Preparations  of  Sixty- 
three  Cases  removed  during  the  Year  1886. 

Mr.  Lawson  Tait  gives,  in  the  Brit.  Med.  Journ.  of  April  16,  1887,  his 
views  of  the  pathology  of  chronic  inflammatory  disease  of  the  uterine  appen- 
dages, as  illustrated  in  a  series  of  63  cases  operated  on  by  him  during  1886. 

Mr.  Tait  recognizes  five  classes  of  cases  as  follows :  First,  catarrhal ;  sec- 
ondly, those  produced  by  the  exanthemata  at  the  time  of  puberty ;  thirdly, 
gonorrheal  cases ;  fourthly,  those  occurring  from  inflammatory  mischief  in 
the  post-puerperal  state ;  and  lastly,  cases  where  the  uterus  is  infantile,  and 
the  appendages  disorganized  by  inflammatory  action. 

The  following  are  the  statistics  of  the  63  cases :  There  was  only  one  death. 
The  gonorrheal  and  post-puerperal  cases  preponderate,  inasmuch  as  53  of 
the  women  were  married,  and  in  3  of  the  unmarried  the  cause  was  undoubt- 
edly gonorrhoea.  One  case  of  double  pyosalpinx  followed  the  prolonged  use 
of  intrauterine  pessaries  intended  to  remedy  an  anteflexion. 

In  every  case  there  was  no  possibility  of  the  woman  becoming  pregnant,  as 
in  the  majority  the  trumpet  of  the  tube  was  found  glued  to  the  ovary;  in 
others  the  fimbriae  were  coalesced,  the  ovary  remaining  free. 

In  one-third  of  the  cases  the  exanthemata,  usually  scarlet  fever,  had  caused 
the  inflammatory  condition.  The  condition  of  the  tubes  varied.  In  the  early 
stages  they  were  intensely  congested  and  friable  ;  in  the  later  cases  the  appen- 
dages were  cirrhotic,  and  few  Graafian  follicles  were  present  in  the  ovaries. 
The  nature  of  the  fluid  contents  varied,  but  was  either  cheesy  or  serous.  He 
did  not  believe  this  had  much  bearing  in  determining  the  patient's  sufferings ; 
this  was  due  to  the  adhesions. 


MEDICAL.  JURISPRUDENCE  AND  TOXICOLOGY. 


UNDER  the  charge  of 
MATTHEW  HAY,  M.D., 

PROFESSOR  OF  MEDICAL  JURISPRUDENCE,  UNIVERSITY  OF  ABERDEEN. 


Statistics  of  Crime  in  Europe. 

According  to  the  journal  V Italic  (Annal.  d' hygiene  publique,  sr.  3,  t. 
xvii.  p.  57),  the  number  of  individuals,  per  100,000  inhabitants,  convicted  of 
homicide  is  in  Italy,  8.12;  Spain,  7.83;  Hungary,  6.09 ;  Austria,  2.24;  Bel- 
gium, 1.78;  France,  1.56;  Germany,  1.11;  Great  Britain,  0.60.    In  respect  of 


292 


PROGRESS  OF  MEDICAL  SCIENCE. 


assaults,  with  injury  to  the  person,  Austria  takes  the  first  place  with  248  per 
100,000  inhabitants;  Belgium,  177;  Italy,  162;  Germany,  129;  France,  65; 
Hungary,  46;  and  Great  Britain  only  7.  For  criminal  (immoral)  assaults, 
the  numbers  are;  Belgium,  15;  Germany,  14;  France,  10;  Austria,  9;  Hun- 
gary, 6.5;  Italy,  4;  Great  Britain,  1.7;  Spain,  1.  In  number  of  convicted 
thieves  of  all  kinds,  Germany  takes  the  highest  place  with  222  per  100,000 
inhabitants;  Italy,  154;  Great  Britain,  147  (Scotland,  222) ;  Belgium,  128; 
France,  112;  Hungary,  77;  Austria,  60;  Spain,  56. 

If  the  figures  for  the  various  crimes  are  added  together  for  each  country,  it 
appears  that  Germany  has  the  greatest  amount  of  criminals,  and  Great  Britain 
the  least,  among  European  nations. 

Contribution  to  the  Medico-legal  Study  of  Footprints. 

Masson  (Annal.  d'hygilne  pubiique,  ser.  3,  tome  xvi.  pp.  336-345,  1886) 
gives  the  results  of  an  investigation  of  a  case  of  murder  in  which  the  foot- 
prints of  the  assassin  were  of  importance.  A  woman  was  found  murdered  in 
an  isolated  house  in  the  neighborhood  of  Constantine.  On  the  floor  of  her 
chamber  were  observed  seven  blood-stained  imprints  of  a  naked  foot,  and 
that  the  right  foot.  Seven  persons  were  suspected  of  the  murder,  and  the 
footprints  had  therefore  to  be  compared  with  the  right  feet  of  all  of  them. 
The  presumption  was  that  all  the  footprints  were  those  of  the  foot  of  one 
individual. 

The  author  regrets  the  meagre  instruction  on  footprints  in  medico-legal 
text-books.  Causse's  well-known  method  of  measuring  footprints  he  did  not 
find  to  be  of  much  service  in  this  case.  The  author  divides  the  investigation 
of  a  footprint  into  three  distinct  operations:  (1)  the  taking  of  the  footprint; 
(2)  its  measurement;  (3)  the  attentive  study  of  its  particular  qualities  or  pe- 
culiarities, which  give  to  each  footprint  a  special  physiognomy.  In  order  to 
take  the  footprint  of  a  suspected  person,  he  is  asked  to  step  on  some  defibrin- 
ated  blood,  or  a  gummy  solution  of  fuchsine,  and  afterward  to  stand  or  walk 
on  a  piece  of  stout  paper,  in  order  to  obtain  a  print  under  both  conditions. 
The  prints  are  then  measured  by  drawing  a  straight  line  along  the  inner  edge 
of  the  print,  touching  the  heel  and  ball  of  the  great  toe.  Then  another  line, 
parallel  to  this,  is  drawn  along  the  outer  side  of  the  print,  and  touching  it. 
These  lines  are  joined  by  three  lines  parallel  to  one  another,  but  at  right 
angles  to  the  first  lines.  One  of  these  lines  touches  the  point  of  the  great 
toe;  another  touches  the  hinder  part  of  the  heel;  and  a  third  passes  across 
the  foot  immediately  behind  the  ball  of  the  great  toe.  The  foot  is  thus  en- 
closed in  a  rectangle,  representing  the  greatest  length  and  breadth  of  the  foot- 
print. It  is  important  to  note  the  distance  between  the  back  of  the  heel  and 
the  front  of  the  print  of  the  ball  of  the  great  toe.  This  measurement  is  less 
variable  than  the  total  length  of  the  footprint.  The  maximal  distance  of  the 
inner  edge  of  the  footprint  from  the  inner  tangential  line  is  also  to  be  meas- 
ured, as  an  index  of  the  height  of  the  plantar  arch.  A  line  is  to  be  drawn 
touching  the  points  of  the  impressions  of  the  second  and  fourth  toes,  and  the 
height  of  the  angle  which  this  line,  when  extended,  forms  with  the  inner 
tangential  line  is  to  be  noted.    It  varies  much  in  different  individuals. 

Masson  carefully  studied  the  variations  in  the  above  measurements,  as  seen 


MEDICAL  JURISPKUDENCE  AND  TOXICOLOGY.  293 


in  different  prints  of  the  same  foot.  He  found  in  twelve  subjects  that  the 
chief  variations  were  as  follows :  9  to  23  millimetres  ( j3^  to  y9^  inch)  in  the 
length  of  the  footprint ;  0  to  8  millimetres  (j3n  inch)  in  its  maximal  breadth  ; 
0  to  5  millimetres  (T2ff  inch)  in  the  measurement  corresponding  to  the  plantar 
arch ;  and  0  to  21  millimetres  (r8o  inch)  in  the  height  of  the  angle  of  the  toes. 
The  extremes  of  the  variations  are  met  with  in  the  prints  from  the  foot  stand- 
ing, and  those  from  the  foot  walking  or  running.  He  found  that  an  added 
weight  of  forty  pounds  does  not  sensibly  alter  the  footprint.  In  studying  the 
physiognomy  of  the  footprint,  attention  is  to  be  paid  to  the  marks  of  the  toes, 
and  especially  to  that  of  the  great  toe.  In  the  latter,  it  is  very  important  to 
distinguish  the  two  parts  of  it;  the  anterior  and  larger  corresponding  to  the 
mass  of  the  toe,  and  the  posterior  and  smaller  (sometimes  wanting)  due  to 
the  flexor  tendon.  This  smaller  part  varies  much  in  different  individuals.  It 
is  rarely  absent  from  the  print  of  the  foot  when  walking,  but  may  be  so  if 
standing.  Applying  these  rules  and  considerations  to  the  particular  case  in 
hand,  Masson  found  a  similarity  between  the  footprints  of  blood  on  the  floor 
of  the  chamber,  and  those  of  one  of  the  suspected  persons.  Other  circum- 
stances afterward  occurred  to  prove  that  this  was  the  murderer. 

Diagnosis  of  Death  by  Hanging. 

Coutagne  (Arch,  de  F anthropologic  crim.  et  des  Sciences  penales,  15  Mai, 
1886)  believes,  contrary  to  the  view  expressed  by  Jardieu,  that  the  diagnosis 
of  death  does  not  depend  essentially  on  the  examination  of  the  exterior  of  the 
body.  The  author  especially  insists  on  attention  being  paid  to  the  internal 
lesions  of  the  neck,  which  are  generally  more  associated  with  judicial  hang- 
ing than  with  suicidal  hanging.  Out  of  24  autopsies  of  suicidal  cases  which 
he  made,  only  5  gave  negative  or  doubtful  results  as  regards  the  internal  ap- 
pearance of  the  neck.  In  17  cases  there  was  hemorrhage  into  the  cellular 
tissue  or  into  the  muscles ;  in  10  cases  there  was  rupture  of  the  muscles ;  in 
8  cases  fracture  of  the  hyoid  bone ;  and  in  8  cases  fracture  of  the  hyoid  carti- 
lage. He  insists  on  the  importance  of  examining  the  soft  parts  at  the  back  of 
the  neck.  The  lungs  of  hanged  persons  present  some  special  characters,  which 
Coutagne  describes  under  the  name  of  carmine  oedema,  and  believes  them  to 
be  dependent  on  an  affection  of  the  pneumogastric  nerves. 

The  Medico-legal  Significance  of  the  Biperforate  Hymen. 

Prof.  Demange,  of  Nancy,  reports  two  cases  of  biperforate  hymen,  and 
both  in  married  women;  the  one  a  young  widow  after  six  years  of  married 
life  without  children,  the  other  a  wife  advanced  in  pregnancy.  In  the  former 
case  a  fibrous  band  passed  anterio-posteriorly  dividing  the  vagina  into  lateral 
halves;  in  the  latter  the  band  passed  transversely  dividing  the  vagina  into 
an  anterior  and  into  a  posterior  part.  Demange  felt  satisfied  that  at  least  in 
the  former  of  the  cases  the  biperforate  hymen  was  not  the  result  of  imperfect 
rupture  during  attempted  coitus.  He  therefore  agrees  with  Delens  and  Cornil, 
and  differs  from  Tardieu,  in  believing  that  a  biperforate  hymen  is  generally  a 
natural  condition,  and  is  not  always,  if  even  frequently,  the  result  of  attempted 
coitus. 


294 


PROGKESS  OF   MEDICAL  SCIENCE. 


Spontaneous  Closure  of  the  Eyelids  after  Death. 

Incited  to  the  investigation  by  the  paper  of  Galezowski  on  "  The  State  of 
the  Eyelids  after  Death,"  read  before  the  Medico-Legal  Congress  in  1878,  Dr. 
Valude  has  made  a  large  number  of  observations  on  this  subject  {Annal. 
d' hygiene  publ.  ser.  3,  t.  xvii.  pp.  168-172).  The  main  question  which  he 
endeavored  to  answer  was,  At  what  time  after  death  do  the  eyelids  close  spon- 
taneously? His  observations  extended  over  one  hundred  bodies.  He  found 
that  during  the  first  twenty-four  hours  after  death  the  eyes  were  completely 
closed  in  7  of  the  cadavers.  In  12  of  these  one  eye  was  closed  and  the  other 
was  open.  In  15  both  eyes  were  widely  open.  In  66  the  eyes  were  moder- 
ately open,  or  half  closed.  He  never  observed  the  eyes  open  spontaneously 
after  they  were  closed,  even  though  he  observed  the  body  for  two  or  three 
days.  In  50  cases,  where  the  eyes  were  observed  to  be  fully  open  or  half  open 
immediately  after  death,  at  a  second  inspection,  some  hours  later,  the  eyes 
were  found  to  have  remained  in  the  same  condition  in  21  of  these,  while  in  23 
the  eyes  had  slightly  closed.  Only  in  one  case  was  a  half-open  eye  found 
next  day  to  be  widely  open.  This  he  considers  quite  exceptional,  and  attrib- 
utes it  to  the  probable  interference  of  the  physician  who  made  the  autopsy. 
He  further  states  that  if  the  eyelids  had  not  begun  to  close  before  the  expira- 
tion of  forty-eight  hours  from  death,  they  seldom  closed  during  the  two  fol- 
lowing days. 

The  author  concludes  (1)  that  in  10  per  cent,  of  subjects  the  eyelids  are 
closed  at  death  ;  (2)  that  in  90  per  cent,  the  eyelids  are  open  or  half  open ; 
(3)  that  in  about  42  per  cent,  of  the  latter  the  eyelids  do  not  change,  while  in 
46  per  cent,  more  or  less  complete  closure  gradually  occurs.  He  believes  it 
to  be  possible,  from  inspection  of  the  eyelids,  to  say  whether  they  had  closed 
spontaneously  or  whether  they  have  been  closed  by  the  hand  of  an  assistant. 
A  whitish  mark  of  the  finger  is,  in  the  latter  case,  left  on  the  upper  eyelid, 
which  is  difficult  to  describe  but  fairly  easy  to  recognize. 

Cicatrices  of  Leech  Bites. 

Dr.  Castro,  of  Italy,  states  {Annal.  d 'hygiene pub!.,  ser.  3,  t.  xvii.  pp.  48-50) 
that  he  recently  had  occasion  to  inquire  into  the  presence  of  scars  as  the  result 
of  leech  bites.  He  made  thirty-seven  experiments  on  different  individuals, 
with  the  result  that  in  several  cases  it  was  impossible  to  discover  a  scar  by  the 
naked  eye.  But  in  such  cases  the  scar  became  evident  after  rubbing  the  skin 
with  tincture  of  mustard,  which  reddens  the  skin  surrounding  the  scar,  leav- 
ing the  scar  white. 

COCAINOMANIA. 

Erlenmeyer  (Deutsche  Mediz.  Zeitung,  1886)  presents  us  with  a  study  of 
this  new  disease,  analogous  to  morphiomania,  and  reports  a  large  number  of 
cases  in  which  patients  have  had  recourse  to  large  doses  of  cocaine  with  the 
object  of  avoiding  the  morphine  habit.  The  results  of  immoderate  use  of 
cocaine  consist  in  symptoms  of  vascular  paralysis,  quick  pulse,  profuse  sweat- 
ings, disturbed  respiration,  and  syncope.  Erlenmeyer  points  out  the  dangers 
to  which  such  persons  are  subject  if  required  to  be  anaesthetized  by  chloroform. 


MEDICAL   JURISPRUDENCE   AND   TOXICOLOGY.  295 


There  is  progressive  emaciation,  as  in  the  case  of  morphiomania,  the  weight 
being  lost  to  the  extent  of  twenty  or  thirty  per  cent.  The  complexion  becomes 
cadaveric,  the  eyes  hollow,  and  the  muscles  flabby.  Sleeplessness  is  a  marked 
symptom.  At  an  advanced  stage  psychical  derangements  manifest  themselves, 
more  especially  of  the  nature  of  delusions  as  to  persecution.  Short  of  this 
there  may  be  hallucinations  of  sight,  with  great  intellectual  depression,  and 
with  loss  of  memory.  In  some  there  is  great  prolixity  in  speech  and  in  writ- 
ing. Some  of  Erlenmeyer's  patients  had  to  be  confined  in  a  lunatic  asylum. 
Erlenmeyer  considers  the  prognosis  of  morphiomania  to  be  very  grave  if  it  is 
associated  with  cocainomania. 


Analogy  between  Dual  Insanity  and  Dual  Suicide. 

Chpolianski  (These  de  Paris,  1885)  points  out  the  following  analysis 
between  dual  suicide  and  dual  insanity : 


Dual  Insanity. 

1.  One  subject  is  insane;  he  im- 
poses his  insanity  on  the  other — im- 
posed insanity. 

2.  Two  subjects  become  insane 
simultaneously  under  the  influence  of 
the  same  cause — simultaneous  insanity. 

3.  Two  subjects,  equally  predis- 
posed, fall  into  the  same  fit  of  mad- 
ness, but  the  one  does  so  first,  the 
other  follows,  compelled  by  the  ex- 
ample of  the  first,  and  by  predisposi- 
tion— communicated  insanity. 

4.  .An  insane  subject  changes  his 
ideas  for  those  of  a  more  intelligent 
madman — transformed  madness. 


Dual  Suicide. 

1.  One  subject  has  the  intention  of 
suicide  ;  he  imposes  it  on  the  other — 
imposed  suicide. 

2.  Two  subjects  intend  suicide  at 
the  same  time  under  the  influence  of 
the  same  cause — simultaneous  suicide. 

3.  Two  subjects  have  the  idea  of 
suicide,  but  the  one  commits  suicide 
first;  the  other,  fascinated  by  the  idea 
or  the  act  of  the  first,  commits  suicide 
at  the  same  time,  or  soon  afterward 
— communicated  suicide. 

4.  An  eccentric  subject  has  his  ideas 
directed  to  suicide  under  the  influence 
of  a  notorious  suicide,  or  in  troublous 
times— transformed  suicide,  or  epidemic 
suicide. 


The  Presence  of  Free  Phosphoric  Acid  as  a  Proof  of  Poisoning  by 

Sulphuric  Acid. 

Professor  G-arnier,  of  Nancy,  investigated  a  case  of  poisoning  by  sul- 
phuric acid,  in  which,  though  indubitable  signs  of  the  mode  of  death  existed 
in  marks  on  the  clothing,  and  in  the  black  carbonized  condition  of  the  alimen- 
tary canal,  as  also  in  the  presence  of  a  trace  of  arsenic — a  common  impurity 
of  sulphuric  acid — in  the  canal,  and  although  the  carbonized  organs  had  a 
strong  acid  reaction,  yet  on  extraction  with  alcohol  and  ether  no  reaction  of 
sulphuric  acid  was  obtainable  from  the  extract.  From  a  further  investigation 
of  the  subject,  Prof.  Gamier  believes  that  in  such  a  case  the  sulphuric  acid 
has  acted  on  the  phosphates  normally  present  in  the  tissues,  and  displaced 
the  phosphoric  acid,  the  latter  acid  then  becoming  the  free  acid  found  in  the 
alimentary  canal.    He  gives  several  experiments  in  support  of  this  view. 


296 


PROGRESS   OF   MEDICAL  SCIENCE. 


Arsenic  m  Soil. 

Professors  Garnier  and  Schlagdenhauffen,  of  Nancy,  recognizing 
the  difficulty  thrown  in  the  way  of  the  investigation  of  cases  of  arsenical 
poisoning  by  the  ever-recurring  suggestion  that  the  arsenic  found  in  the  dead 
body  has  entered  the  body  otherwise  than  in  the  form  of  poison,  have  made 
an  experimental  inquiry  (Annales  dJ  hygiene  publique,  ser.  3,  t.  xvii.  pp.  28-37, 
1887)  into  the  subject.  They  divide  the  methods  by  which  arsenic  may  enter 
the  body  in  other  form  than  poison  into  four  groups:  (1)  the  introduction  of 
arsenic  into  the  organism  before  death  in  the  form  of  medicine,  as  Fowler's 
solution,  in  ordinary  doses,  or  in  the  form  of  drugs  containing  a  trace  of 
arsenic  as  an  impurity,  as  subnitrate  of  bismuth,  sulphate  of  potash,  etc.; 
(2)  the  introduction  of  arsenic,  also  before  death,  in  foods  and  drinks,  the 
organic  matters  from  which  these  are  prepared  containing  arsenic  as  an  im- 
purity— e.  g.,  sugar,  confections,  wine  and  beer;  (3)  the  imbibition  of  arsenic 
by  the  dead  body  from  the  arsenical  soil  of  the  cemetery  in  which  it  is  buried; 
(4)  the  imbibition  of  arsenic  from  the  colored  clothes  in  which  the  corpse  may 
have  been  buried,  or  from  the  paint  and  metal  mountings  of  the  coffin. 

The  authors  in  their  present  investigation  have  confined  themselves  to  the 
investigation  of  the  third  of  these  groups,  and  have  made  three  sets  of  experi- 
ments, with  the  following  results : 

I.  Examination  of  soils  naturally  arsenical.  Arsenic  is  found  disseminated 
in  various  soils  in  the  Vosges  in  variable  but  often  in  considerable  quantity, 
especially  in  red  colored  soils.  The  arsenic  is  present  probably  in  the  form 
of  arseniate  of  iron.  This  salt  is  very  slightly  soluble  in  boiling  water,  but  it 
is  completely  insoluble  in  water  at  the  ordinary  temperature  of  the  soil.  It 
cannot  therefore  be  dissolved  out  by  the  percolating  rain. 

II.  Absorption  of  soluble  arsenical  compounds  by  non-arsenical  soil  in  pres- 
ence of  water.  The  soil  chosen  for  this  set  of  experiments  was  taken  from 
the  cemetery  of  Preville,  Nancy.  It  was  perfectly  free  from  even  a  trace  of 
arsenic.  It  is  calcareous  and  of  yellowish  color,  containing  a  considerable 
quantity  of  ferric  oxide.  A  given  quantity  of  the  soil  was  mixed  with  twice 
its  weight  of  distilled  water,  and  to  this  was  added  a  certain  quantity  of  a 
weak  solution  of  arsenious  acid.  A  portion  of  the  supernatant  fluid  was  from 
time  to  time  removed  and  tested  for  arsenic.  It  was  found  that  after  six  or 
seven  months  the  water  contained  no  arsenic  in  solution.  It  had  all  become 
deposited  in  the  form  of  arseniate  of  iron.  Heat  facilitated  the  disappearance 
of  the  arsenic. 

III.  Diffusion  of  arsenic  into  a  non- arsenical  soil,  in  contact  with  soluble 
and  insoluble  compounds  of  arsenic.  Two  ordinary  graves  were  dug  in  the 
Preville  Cemetery,  side  by  side,  one  of  which  was  afterward  filled  up  and  the 
other  kept  open.  Four  months  later,  cartridges  made  of  white  filtering  paper, 
and  containing  each  five  grammes  of  arseniate  of  iron,  arseniate  of  lime,  or 
arseniate  of  potassium,  were  introduced  by  a  boring  process  from  the  sides  of 
the  open  grave  into  the  surrounding  soil  and  into  the  grave  which  had  been 
filled  up.  At  different  periods  subsequently  the  soil  surrounding  the  cartridges 
were  removed  and  examined  for  arsenic.  No  arsenic  was  at  any  time  discovered 
except  in  the  case  of  the  soil  surrounding  the  cartridges  containing  arseniate 
of  lime,  where  a  minute  trace  of  arsenic  was  recognizable  by  Marsh's  method. 


MEDICAL   JURISPRUDENCE   AND  TOXICOLOGY. 


297 


The  arseniate  of  potassium  had  disappeared,  but  had  evidently  been  converted 
into  insoluble  compounds  as  soon  as  it  came  in  contact  with  the  surrounding 
soil.  The  authors  conclude  that  the  arsenical  compounds  met  with  in  soil 
are  not  likely  to  diffuse  themselves  into  the  body  of  a  buried  person. 

Mode  of  Action  of  Sulphuretted  Hydrogen  and  Alkaline 

Sulphides. 

Julius  Pohl,  in  the  Archiv  f.  Experimentelle  Pathologie  u.  Pharmakologie 
(Bd.  xxii.  p.  1-25),  gives  the  results  of  an  investigation  of  the  above  sub- 
ject, which  he  conducted  in  the  pharmacological  laboratory  at  Prague. 
His  experiments  were  made  on  frogs  and  rabbits,  and  in  two  instances  on 
dogs.  Assuming  that  sulphuretted  hydrogen,  when  it  mixes  with  the  blood, 
becomes  converted  into  an  alkaline  sulphide,  he  employed  a  neutral  solution 
of  sulphide  of  sodium  in  nearly  all  his  experiments,  injecting  it  into  the 
lymph-sac  of  the  frog  and  the  jugular  vein  of  the  rabbit  and  dog.  The  symp- 
toms in  the  case  of  frogs,  when  a  dose  of  0.01  gramme  (0.15  grain)  was  em- 
ployed, were  remarkably  constant,  and  consisted  of  narcosis,  central  motor 
paralysis,  slowing  of  the  heart,  with  general  enfeeblement  of  the  cardiac 
muscle,  ending  with  stopping  of  the  heart  in  diastole.  Fibrillar  twitchings  of 
the  muscles  were  also  observed.  Death  occurred  in  one  and  a  half  to  two  and 
a  half  hours,  when  a  large  dose  was  injected;  in  six  or  more  hours  when  a 
smaller  close  was  given.  In  some  cases  rigidity  of  the  muscles  was  observed. 
The  poisonous  symptoms  in  rabbits  were  not  so  constant  as  in  frogs.  In 
almost  every  case  violent  convulsions  were  present,  with  deep,  labored  breath- 
ing, plaintive  cries,  and  slight  tremors  of  the  muscles.  The  convulsions  were 
proved  to  be  of  cerebral  origin.  In  the  few  cases  in  which  convulsions  were 
absent,  a  general  and  gradually  increasing  paralysis  of  the  muscles  was 
observed,  with  increased  frequency  of  the  respirations,  and  general  exhaus- 
tion, ending  in  death.  The  lethal  dose  of  the  sulphide  injected  into  the  vein 
was  about  one  and  a  half  to  two  grains  for  an  adult  rabbit  (about  one-twentieth 
of  a  grain  for  each  pound).  Such  a  dose  proves  fatal  in  about  an  hour.  The 
"blood,  though  dark  in  color,  contained  oxy-hsemoglobin,  and  no  sulph-hsemo- 
globin.  In  a  few  cases  the  haemoglobin  was  reduced.  The  blood  pressure 
rapidly  sank,  even  after  very  small  injections.  This  was  probably  due  to  the 
action  of  the  sulphide  on  the  vasomotor  centres. 

In  order  to  ascertain  whether  the  toxic  action  of  the  sulphide  was  due  to 
its  oxidized  products,  experiments  were  made  with  sulphite  and  hyposulphite 
of  sodium,  but  although  much  larger  doses  than  those  of  the  sulphide  were 
injected,  no  effect  was  observed  on  the  blood  pressure  or  otherwise.  The 
toxic  action,  was,  therefore,  not  due  to  oxidized  products,  nor  was  it  caused 
by  the  sulphide  abstracting  oxygen  from  the  -blood;  for  the  symptoms  were 
not  those  of  asphyxia,  nor  were  similar  symptoms  observed  when  strong 
reducing  substances  were  injected  into  the  blood,  such  as  hyposulphite  of 
sodium,  hypophosphite  of  sodium,  phosphite  of  sodium,  aldehyde,  acetone, 
pyrogallol,  etc.  Some  experiments  were  made  by  digesting  the  sulphide  with 
defibrinated  blood,  and  then  injecting  it  into  the  jugular  vein.  A  lethal 
result  was  still  obtained,  but  the  symptoms  were  somewhat  different  from 
those  of  the  pure  sulphide.    The  well-marked  action  on  the  blood  pressure 


298 


PROGRESS  OF   MEDICAL  SCIENCE. 


was  wanting.  The  author  is,  therefore,  of  opinion  that  the  toxicity  of  the 
sulphide  is  due  to  its  own  action  on  the  tissues,  and  not  to  the  action  of  oxi- 
dized products  or  other  transformations  of  it. 


PUBLIC  HEALTH. 


UNDER  THE  CHARGE  OF 

SHIRLEY  F.  MURPHY,  M.R.C.S, 

LECTURER  ON  HYGIENE  AND  PUBLIC  HEALTH,  ST.  MARY'S  HOSPITAL,  LONDON. 


Vaccination  in  Russia. 

Dr.  Ucke  gives  an  interesting  account  of  the  present  condition  of  vaccina- 
tion in  Russia.  The  benefits  of  vaccination,  he  says,  are  only  now  beginning 
to  be  realized  by  the  peasants  in  Russia.  As  early  as  1811  the  Emperor 
ordered  that  all  medical  men  should  vaccinate;  and  that  peasants,  chosen 
from  certain  districts,  should  be  educated  in  this  particular  at  the  cost  of  the 
community,  and  sent  into  the  provinces  to  vaccinate.  Annual  reports  were 
sent  to  the  authorities,  but  it  was  soon  shown  that  vaccination  was  not  pro- 
ducing any  effect  on  the  smallpox  epidemics  which  decimated  the  country. 
At  first  it  was  believed  to  be  the  lymph;  but  even  though  animal  lymph  was 
employed,  the  result  was  the  same.  It  was  then  thought  necessary  that  some 
control  should  be  exercised  over  the  vaccinators,  and  accordingly  this  work 
was  added  to  that  already  occupying  the  medical  inspector  of  each  province. 
This  again  failed,  and  it  was  easily  explained.  In  63  provinces,  each  having 
an  area  of  1500  square  miles,  5000  villages,  and  about  80,000  children,  there 
was  but  one  inspector,  and  he  could  only  vaccinate  at  such  times  as  the  peas- 
ants were  not  occupied  in  cultivating  their  land — i.  e.,  in  the  winter  time,  an 
impossibility  with  such  a  climate  as  that  possessed  by  Russia.  Thus  vaccina- 
tion ceased  to  be  enforced  almost  until  1881,  when  local  self-government  hav- 
ing been  given  to  thirty-four  provinces,  it  was  determined  to  appoint  a  com- 
mission to  consider  the  question  of  vaccination.  The  territory  which  it  was 
thus  proposed  to  deal  with  consisted  of  the  whole  of  the  central  provinces  of 
European  Russia,  with  the  exception  of  Poland,  the  Baltic  Provinces,  the 
country  of  the  Cossacks,  and  the  provinces  of  Archangel,  Astrachan,  and 
Orenburg,  and  it  has  an  area  of  51,444  square  miles,  about  53,000,000  of  popu- 
lation, and  probably  2,710,000  children  amongst  them.  These  34  provinces 
are  divided  into  360  districts;  each  of  these  manages  its  affairs  for  itself,  and 
up  to  1864  there  was  only  one  hospital  of  twenty  beds  in  each  district,  and  a 
peasant  vaccinator  in  each  village.  These  hospitals  were  somewhat  improved 
after  this  date,  and  Jie  vaccination  was  left  to  dressers,  instead  of  to  the  peas- 
ants; but  there  was  no  control  over  the  medical  inspectors,  who,  in  some 
places,  left  everything  to  the  dressers,  in  others  allowed  people  to  come  to 
them,  and  in  others  sought  them  out  in  their  own  homes.    The  vaccination 


PUBLIC  HEALTH. 


299 


report  for  1882  stated  that  at  least  one-third  of  the  children  were  unvacci- 
nated,  and  probably  that  was  not  stating  the  whole  truth. 

The  Commission  was  occupied  first  with  the  question  of  the  production  of 
lymph,  then  with  vaccinators,  and  thirdly  with  arranging  the  plan  by  which 
vaccinations  were  to  take  place  regularly,  and  how  systematic  control  could 
be  exercised  over  all  vaccinations. 

After  but  a  short  discussion,  it  was  decided  to  use  animal  lymph  on  account 
of  the  prevalence  of  syphilis  in  Russian  villages,  and  the  fear  that  arm-to-arm 
vaccination  would  aid  in  spreading  the  disease.  As  but  few  doctors  and 
dressers  could  maintain  a  supply  of  animal  lymph,  it  was  determined  to  keep 
up  a  central  station,  where  vaccination  could  be  efficiently  taught  and  lymph 
obtained  for  distribution. 

Hitherto,  also  in  Russia,  owing  to  the  distances  to  be  traversed,  and  the 
scarcity  of  medical  men,  vaccination  was  left  to  "dressers,"  and  this  the  Com- 
mission considered  must  be  continued,  only  that  a  medical  man  should  control 
each  of  these  people,  and  ascertain  that  his  work  was  properly  performed, 
and  measures  should  also  be  taken  to  have  them  better  instructed. 

The  system  thus  designed  is  for  the  priests  in  every  district  to  send  at  a  fixed 
period  a  list  of  all  the  children  born  during  the  past  year.  A  list  of  the  num- 
ber of  villages  is  sent  to  a  dresser,  with  the  dates  when  he  is  expected  to  visit. 
Upon  his  arrival  at  the  first  village  he  vaccinates  a  calf,  and  then  goes  to  the 
next  village,  leaving  directions  for  the  management  of  the  first  calf,  there  he 
does  the  same,  and  also  on  the  third  day.  The  fourth  day  he  returns  to  the 
first  village,  takes  lymph,  vaccinates  the  children,  and  continues  his  journey, 
so  that  in  six  days  he  has  vaccinated  in  three  villages,  and  has  also  obtained 
lymph  sufficient  for  the  next  villages.  In  every  village  he  leaves  a  report  of 
whom  he  has  vaccinated.  As  soon  after  as  the  pustules  might  be  considered 
to  be  developed,  the  doctor  arrives  with  two  dressers;  he  is  provided  with 
lymph,  in  case  of  failure  of  those  previously  operated  upon,  and  thus  he 
examines  and  journeys  through  all  the  villages  previously  vaccinated  by  the 
dresser.  The  work  is  so  arranged  that  only  twenty-four  days  in  the  month 
are  counted  upon,  because  of  possible  hindrances,  and  only  during  nine 
months  of  the  year,  because  of  the  work  in  the  fields  during  the  other  three 
months.  The  number  of  medical  men  and  dressers  varies  according  to  the 
size  of  the  district  and  number  of  inhabitants  to  each  mile.  When  the  expe- 
dition is  over,  the  lists  of  those  vaccinated  are  written  up  and  sent  in  to  the 
authorities. 

Thus  it  will  be  seen  that  the  ambulatory  system  of  medical  attendance  will 
be  the  most  useful  for  a  country  like  Russia,  the  only  danger  to  be  guarded 
against  is  the  scarcity  of  medical  men,  not  less  than  one  for  every  hundred 
villages  being  necessary. 

Besides,  in  journeying  every  year  through  the  districts,  the  doctors  will 
learn  the  habits,  customs,  and  diseases  of  the  inhabitants,  they  will  have  leisure 
to  prescribe  for  and  visit  their  patients,  and  the  dressers  will  be  useful  in  visit- 
ing patients  and  preparing  medicines.  Every  medical  man  is  to  be  provided 
with  a  medico-topographical  list  of  questions,  in  order  that  he  may  obtain 
information  from  all  the  villages,  and  that  which  he  fails  to  obtain  one  year 
may  be  asked  for  the  following,  until  a  perfect  history  of  all  distric  ts  can  be 
collected. 


300 


PKOGRESS  OF   MEDICAL  SCIENCE. 


What  results  this  new  vaccination  legislation  will  produce  can  only  be  seen 
after  many  years  of  work. — Deutsche  Vierteljahrsschrift  filr  bffentliche  Gesund- 
heitspflege,  Bd.  xviii.  Heft  3,  1886. 

Influence  of  Smallpox  Hospitals. 

The  Local  Government  Board  of  England  have  recently  issued  the  report 
of  their  medical  officer,  Dr.  George  Buchanan,  F.K.S.,  which  contains  a 
resurn'e  of  the  evidence  which  has  been  adduced  as  to  the  influence  of  small- 
pox hospitals  situated  in  London.  Everyone  of  the  five  hospitals  under  the 
control  of  the  Metropolitan  Asylums  Board,  and  also  two  others  under  differ- 
ent management,  have  given  rise  to  smallpox  in  their  neighborhood.  The 
influence  of  the  hospital  at  Fulham  had  been  especially  investigated  by  the 
Board's  medical  inspector,  Mr.  W.  H.  Power,  and  Dr.  Buchanan  now  states 
that  the  whole  of  the  experiences  on  record  concerning  the  districts  of 
London  which  are  in  special  relations  with  smallpox  hospitals,  combine  to 
form  a  very  strong  corroboration  of  the  view  of  the  Commission  of  1881, 
that  in  the  metropolis  all  smallpox  hospitals  share  the  disastrous  ability  of 
the  Fulham  hospital  to  spread  smallpox  by  some  means  or  other  over  the 
neighborhoods  around  them.  This  ability  is  now  proved  to  extend  to  the 
distance  of  at  least  a  mile,  and  to  be  independent  of  lines  of  human  commu- 
nication. It  has  now  been  shown  to  be  exerted  when  the  number  of  acute 
cases  in  a  hospital  has  been  restricted  to  twenty  or  thirty,  and  it  was  on  one 
occasion  exerted  when  only  five  acute  cases  were  in  the  hospital  together.  It 
has  not  been  extinguished,  as  Mr.  Power's  recent  researches  and  the  reports 
of  health  officers  show,  by  the  regulation  of  methods  of  transit,  or  by  the 
removal  of  opportunities  for  personal  communication  with  patients  in  the 
hospital. 

It  is  to  this  influence  of  hospitals  in  maintaining  smallpox  over  large  areas 
of  the  metropolis,  that  must  needs  be  ascribed  a  measure  of  that  excess  which 
has  recently  become  conspicuous  in  the  smallpox  death-rate  of  London  as 
compared  with  that  of  the  provinces.  This  changed  attitude  of  London 
toward  the  provinces,  dating  from  the  time  when  the  former,  and  not  the 
latter,  became  plentifully  supplied  with  hospitals  for  smallpox,  deserves  espe- 
cial consideration  by  any  whose  first  thought  is  for  the  aggregate  metropolis. 
For  those  whose  concern  is  with  the  particular  sections  of  London  the  facts 
will  suffice  that  the  five  intra-urban  smallpox  hospitals  in  London  have  excess 
of  smallpox  around  them,  and  that  in  the  case  of  the  hospital  which  has  been 
especially  studied  (Fulham),  this  excess  has  amounted  (during  such  portions 
of  ten  years  as  have  seen  the  hospital  at  work,  but  not  during  other  portions 
of  the  ten  years  when  it  was  shut)  to  a  threefold  incidence  of  smallpox  upon 
the  three  nearest  square  miles  as  compared  with  the  incidence  on  the  remain- 
ders of  circumjacent  districts.  Dr.  Buchanan  therefore  submits  that  the  time 
has  now  come  when  the  other  means  recommended  by  the  Commission  for 
"  reducing  the  chance  of  spreading  infection  "  ought  to  be  tried. 

The  volume  also  contains,  in  appendix,  a  detailed  memorandum  on  "  Further 
Observation  (1884-85)  of  the  Influence  of  Fulham  Smallpox  Hospital  on  the 
Neighborhood  Surrounding  It,"  by  Mr.  W.  H.  Powers.  The  memorandum 
shows  that  when  circles  are  drawn  round  the  hospital  having  respectively  a 


PUBLIC  HEALTH. 


301 


quarter  mile,  half  mile,  three-quarter  mile,  and  one  mile  radius,  there  has 
been  the  greatest  incidence  of  smallpox  upon  that  nearest  to  the  hospital,  and 
a  less  incidence  on  every  successive  ring  in  proportion  as  it  is  distant  from  the 
hospital ;  that  this  is  equally  true  for  each  of  the  segments  produced  by  di- 
viding the  area  round  the  hospital  by  lines  running  from  north  to  south  and 
from  east  to  west,  and  is  further  true  when  these  lines  are  drawn  from  north- 
west to  southeast,  and  from  northeast  to  southwest.  It  should  be  noted  that 
during  the  period  when  the  hospital  had  this  influence,  every  practical  means 
had  been  taken  for  limiting  the  number  of  communications  between  the  hos- 
pital and  the  outside  world,  and  for  rendering  any  danger  to  outsiders  from 
such  communications  infinitesimal ;  an  excellent  ambulance  service  has  been 
provided ;  and  the  number  of  sick  in  the  hospital  at  any  one  time  has  been 
kept  down  even  below  the  limit  which  the  Hospital  Commission  regarded  as 
permissible. 

On  the  Etiology  of  Foot  and  Mouth  Disease. 

A  valuable  paper  on  this  subject  is  communicated  by  Dr.  E.  Klein,  F.R.S., 
to  the  same  volume.  He  began  his  investigation  by  the  examination  of  the 
organisms  found  in  the  tissue  of  the  vesicle  of  the  foot  of  the  sheep.  Two 
kinds  of  organisms  were  found  in  the  diseased  tissue :  (a)  bacilli  of  the  size  of 
tubercle  bacilli,  these  stained  in  fuchsin  after  Gram's  method,  resembled  the 
bacilli  described  by  Gottstein  and  others  as  occurring  normally  in  sebum  in 
between  the  epithelial  cells  of  sebaceous  glands;  (b)  small  micrococci  occur- 
ring singly  as  dumb-bells,  and  particularly  as  longer  or  shorter  chains  or 
streptococcus ;  their  number  was  not,  on  the  whole,  very  large,  but  they  were 
present  in  all  the  sections;  they  occur  in  the  cavities  of  the  vesicles  and 
amongst  the  superficial  parts  as  well  as  amongst  the  cell  infiltrations  of  the 
deeper  parts  of  the  corium.  They  are  found  less  abundant  in  the  vesicle 
stage,  more  abundant  in  the  formed  ulcers,  most  abundantly  in  the  superficial 
exudation  of  the  ulcer  of  the  mouth. 

Inoculation  of  tubes  containing  sterile  nutritive  gelatine,  or  sterile  agar- 
agar  meat  extract  peptone,  with  lymph  taken  from  a  vesicle,  led  to  definite 
results.  In  one  gelatine  and  one  agar-agar  tube  the  growth  on  microscopic 
examination  proved  a  motile  bacillus;  this,  as  it  increased  in  number,  lique- 
fied the  gelatine,  and  formed  a  pellicle  on  the  surface.  In  size  and  other 
characters  it  was  comparable  to  a  small  species  of  bacillus  subtilis.  In 
another  gelatine  tube,  and  in  two  other  agar-agar  tubes,  the  growth  had  alto- 
gether different  characters,  its  progress  was  extremely  slow,  and  after  sixteen 
days'  exposure  to  36°  C.,  the  growth  consisted  of  small  collections  of  translu- 
cent, round,  flat  droplets  or  granules  placed  closely  side  by  side.  From  one 
of  these  agar-agar  tubes  subcultures  were  established  in  a  series  of  tubes  con- 
taining gelatine,  agar-agar,  serum,  sterile  milk,  sterile  broth,  meat  extract  solu- 
tion with  peptone  (1  per  cent.),  and  sterile  broth  with  peptone  (1  per  cent.). 

In  the  ordinary  fluid  media  there  appears  as  soon  as  twenty-four  hours 
after  incubation  at  35°  C.  a  very  slight  and  uniform  turbidity,  which  increases 
during  the  next  few  days;  at  the  end  of  a  week  the  growth  has  reached  its 
maximum,  but  the  turbidity  is  not  at  any  time  very  great;  before  this  point 


302 


PKOGRESS  OF   MEDICAL  SCIENCE. 


is  reached  some  growth  begins  to  settle  down  as  a  white  powdery  mass,  and 
after  ten  or  twelve  days  or  so  the  fluid  has  become  quite  clear,  the  whole 
having  settled  down.  In  sterilized  milk  it  proceeds  more  slowly.  A  very 
remarkable  difference  exists  between  cultures  in  milk  and  in  other  fluid 
media;  the  growth  in  milk  remains  alive  even  after  lapse  of  several  months, 
in  other  fluid  media,  kept  for  three,  four,  or  more  weeks,  the  growth  appa- 
rently becomes  void  of  life.  Microscopic  examinations  made  of  the  growth 
from  fluid  media  show  it  to  consist  of  dumb-bell  micrococci,  diplococci,  but 
chiefly  of  chains,  streptococci,  composed  of  4,  6,  8,  12,  16,  or  more  elements 
serially  arranged. 

Sheep,  pigs,  and  guinea-pigs,  inoculated  with  the  streptococcus,  did  not 
suffer  any  noticeable  illness ;  injection  of  a  comparatively  large  quantity  of 
the  streptococcus  into  the  cavity  of  the  trachea  in  the  case  of  two  sheep 
and  three  calves  failed  to  induce  in  these  animals  foot  and  mouth  disease, 
but  feeding  four  sheep  with  cultures  of  streptococcus  induced  in  two  of  them 
the  typical  disease  on  the  feet,  a  third  animal  showing  lameness  without 
other  evidence  of  having  contracted  the  malady ;  while  the  fourth  remained 
well.  On  the  other  hand,  certain  guinea-pigs  fed  with  the  same  streptococcus 
did  not  suffer  from  foot  and  mouth  disease,  but  three  of  them  died  with  dis- 
ease of  the  stomach,  which  seemingly  was  of  like  nature  in  all  cases.  In 
two  sheep  the  feeding  of  the  streptococcus  had  to  be  repeated  three  times 
before  one  became  infected.  The  symptoms  of  foot  and  mouth  disease  were 
well  marked,  and  from  the  vesicle  upon  the  foot  of  one  of  the  sheep  lymph 
was  taken  and  used  for  the  inoculation  of  culture  tubes,  each  of  which  showed 
after  a  few  days  the  characteristic  growth  of  the  streptococcus.  It  is  note- 
worthy that  five  sheep  previously  inoculated  did  not  suffer  from  foot  and 
mouth  disease  when  subsequently  fed  with  the  streptococcus,  their  immunity 
being  in  all  probability  due  to  their  having  been  rendered  refractory  by  the 
previous  subcutaneous  inoculation. 

Dr.  Klein  adds,  if  a  previous  subcutaneous  inoculation  with  the  virus, 
though  it  does  not  effect  any  conspicuous  disturbance  of  the  general  health, 
renders  the  animals  experimented  on  thenceforward  insusceptible  to  foot  and 
mouth  disease,  a  means  would  have  been  found  to  protect  some  animals  at 
least  against  the  virulent  form  of  this  disorder ;  but  for  a  completely  satis- 
factory settlement  of  the  question,  cattle  as  well  as  sheep  require  to  be  experi- 
mented on,  since  cattle  are  the  most  susceptible  of  animals  as  regards  foot  and 
mouth  disease. 

Epidemic  of  Enteric  Fever  at  Pierrefonds. 

Kecently,  Mons.  Brouardel  brought  before  the  Academie  des  Sciences  a 
report  on  the  prevalence  of  enteric  fever  at  Pierrefonds.  He  stated  that 
during  August  and  September  of  last  year  (1886)  23  persons  inhabited  three 
houses  adjoining  each  other,  of  these,  20  were  attacked  with  fever,  and  4 
died,  8  were  seriously  ill,  while  several  hardly  suffered  at  all.  The  three  who 
were  not  attacked  had  only  resided  in  the  locality  a  short  time.  Previously, 
in  July,  one  person  had  been  seized  with  illness  after  occupying  one  of  the 
houses,  and  from  1874  to  1883  this  group  of  houses  was  five  times  visited  by 


PUBLIC  HEALTH. 


303 


enteric  fever.  The  street  where  these  houses  are  situated  lies  at  the  foot  of  a 
hill,  and  the  drinking  water  is  obtained  from  a  bed  of  clay  covered  by  a  layer 
of  porous  sand,  about  two  to  three  feet  deep,  and  on  which  are  built  these 
houses.  In  order  to  procure  the  water,  holes  in  the  form  of  wells  were  dug 
to  the  depth  of  2  to  3  feet.  These  wells  were  only  distant  9  to  20  feet  from 
leaking  cesspools,  some  of  which  had  not  been  emptied  for  30  years;  besides 
which,  the  rain-water  from  the  roofs  was  conducted  direct  into  these  cess- 
pools, so  that  after  heavy  showers  they  overflowed,  and  saturated  the  sur- 
rounding soil  with  excremental  matter.  But  in  order  to  demonstrate 
more  clearly  that  the  water  was  responsible  for  the  outbreak  of  disease, 
samples  were  taken  from  different  wells,  and  examined  by  MM.  Chante- 
messe  and  Widal,  of  the  Bacteriological  Laboratory  in  Paris,  who  reported 
that  they  had  found  bacilli  resembling  those  which  Eberth,  Gaffky,  and 
others  considered  to  be  the  enteric  fever  bacillus,  and  these  were  found  alive 
one  month  after  the  outbreak.  The  spleen  of  one  of  the  patients  was  punc- 
tured, and  blood  from  it  also  produced  colonies  of  bacilli  similar  to  those  in 
the  water.  The  water  from  the  wells  was  also  chemically  analyzed,  and  that 
which  came  from  the  house  where  the  bacilli  were  most  numerous,  contained 
least  evidence  of  pollution,  there  being  only  8  to  9  milligrammes  of  organic 
matter  in  a  litre. 

M.  Brouardel's  conclusions  were  that  the  earth  does  not  destroy  the  germs 
of  enteric  fever;  that  they  existed  more  than  a  month  in  the  water  of  one  of 
the  wells  at  Pierrefonds;  he  states,  however,  that  organic  matter  may  be 
entirely  destroyed  if  it  comes  in  contact  with  any  alkali. — Journal  de  Hygilne, 
No.  544,  p.  93.' 

Treatment  of  Sewage. 

Mr.  Crump  and  Mr.  Dibdin  read  papers  on  the  treatment  of  sewage  at  a 
meeting  of  the  Institution  of  Civil  Engineers  in  London,  in  which  the  former 
pointed  out  that  filter  presses  afford  a  ready  solution  to  the  question  of  the 
disposal  of  the  sloppy  mass  of  putrescent  mud  daily  produced  in  sewage  pre- 
cipitation works,  and  that  a  practically  inodorous  manure  might  be  obtained, 
more  valuable  for  crops  of  hay,  potatoes,  Swedish  turnips,  etc.,  than  any  farm- 
yard manure.  Mr.  Dibdin,  however,  in  his  paper,  though  considering  that 
sewage  sludge  presses  are  useful  in  converting  the  material  into  a  portable  form, 
did  not  believe  that  they  would  ever  be  really  successful  except  for  small 
quantities;  the  cost,  also,  is  an  almost  insuperable  obstacle.  He  believed 
the  furnace,  rather  than  the  farm,  will  be  found  the  most  suitable  way  of 
disposing  of  unwholesome  matter.  In  some  places,  where  the  quantity  is 
small,  it  can  be  mixed  with  freshly  slacked  lime,  and  theu  run  out  on  to 
porous  beds,  where  after  a  few  days,  it  will  be  found  hard  enough  to  cut 
with  a  spade  and  remove;  or,  as  in  Southampton,  where  dry  road  sweepings 
are  mixed  with  semi-liquid  sludge,  and  made  suitable  for  the  use  of  the 
farmer.  But  with  regard  to  London,  the  only  plan  that  seemed  likely  to 
succeed  would  be  to  carry  the  sludge  out  to  sea,  no  expense  would  be  incurred 
in  pressing;  the  sludge  need  not  be  visible  at  all,  it  could  be  precipitated  in 
covered  tanks,  pumped  into  vessels,  and  discharged  under  water,  far  from  land, 


304 


PROGRESS  OF   MEDICAL  SCIENCE. 


in  the  most  cleanly  and  efficient  manner.  The  possible  objections  to  this 
course  were  the  waste  of  manure,  which,  however,  is  almost  proved  to  be  of 
little  value,  the  nuisance  on  the  coast,  which  could  hardly  be  created  if  the 
system  was  carried  out  with  care,  and  the  difficulty  arising  from  fogs  and 
bad  weather,  which  could  not  be  considered  a  real  objection.  This  plan, 
he  acknowledged,  though  it  might  be  suitable  for  London,  need  not  be 
regarded  as  the  only  one  for  other  towns,  the  recent  Royal  Commission 
having  recommended  various  methods,  such  as  the  application  of  sludge  to 
the  raising  of  low  lands,  burning,  or  digging  into  the  land,  the  last  process 
being  that  adopted  in  Birmingham,  where  the  soil  is  mostly  gravel,  and 
suitable  for  the  purpose.  Chemical  precipitation  is  powerless  to  do  more  than 
remove  a  certain  proportion  of  the  oxidizable  organic  matter  in  sewage,  and 
Mr.  Dibdin  pointed  out  that  sulphate  of  iron  used  in  conjunction  with  lime, 
could  perform  more  than  twice  as  much  work  as  alumina  and  lime ;  he  also 
stated  that  the  system  of  filtration  as  an  alternative  to  precipitation,  is  a 
failure,  owing  to  the  expense,  the  choking  of  the  filters,  the  frequent  cleans- 
ing, and  heavy  manual  labor  required. — Sanitary  Record,  vol.  viii.  part  94. 

There  is  now  in  use  at  Walthamstow,  Essex,  a  well  contrived  machine,  the 
invention  of  Mr.  Astrop,  for  extracting  water  from  sludge.  The  sludge  is  first 
received  into  a  large  vat,  in  which  are  two  hollow  perforated  metal  cylinders, 
covered  with  fine  wire  gauze,  which  is  kept  clean  by  the  cylinders  constantly 
revolving  against  brushes;  a  partial  vacuum  is  created  in  these  cylinders  by 
pumping,  and  about  60  per  cent,  of  the  moisture  is  extracted,  the  sludge  then 
passes  by  a  sluice-valve  on  to  an  endless  web  of  travelling  wire  gauze  of  the 
width  of  the  machine,  and  having  the  same  sized  mesh  as  the  cylinders.  The 
web  is  carried  on  rollers,  and  passes  beneath  other  rollers,  and  also  over  one 
of  Korting's  exhausters,  by  which  10  per  cent,  of  the  moisture  is  removed. 
It  next  passes  between  rollers  provided  with  scrapers,  and  then  falls  into  a 
hopper,  whence  it  is  conveyed  into  a  disintegrating  cage  on  the  lower  floor ; 
in  this  cage  it  loses  more  of  its  fluid  by  being  exposed  to  a  blast  of  warm  air, 
and  thus  is  converted  into  a  powder,  which  contains  but  5  per  cent  of  its 
original  moisture.  In  this  form  it  falls  through  the  meshes  of  the  disinte- 
grator on  to  an  Archimedean  screw  by  which  it  is  conveyed  to  a  distance  and 
falls  into  bags. — Lancet,  1887,  vol.  i.  No.  11,  page  287. 


University  of  the  City  of  New  York. 

MEDICAL  DEPARTMENT. 

410  East  Twenty-Sixth  Street,  opposite  Bellevue  Hospital,  t\ew  York  City. 

FORTY-SEVENTH   SESSION,  1887-88. 
FACULTY   OF  MEDICINE. 


REV.  JOHN  HALL,  D.D.,  LL.D.,  Chancellor  of 
the  University. 

REV.  HENRY  M.  McORACKEN,  D.D.,  Vice- 
Chancellor. 

CHARLES  INSLEE  PARDEE,  M.D.,  Dean  of  the 

Faculty ;  Professor  of  Otology. 
J.  W.  S.  ARNOLD,  M.D.,  Professor  Emeritus  of 

Physiology  and  Histology. 
ALFRED  L.  LOOMIS,  M.D.,  LL.D.,  Professor  of 

Pathology  and  Practice  of  Medicine  ;  Physician 

to  Bellevue  Hospital. 
WILLIAM  H.  THOMSON,  M.D.,   LL.D.,  Pro- 
fessor of  Materia  Medica  and  Therapeutics ; 

Diseases  of  the  Nervous  System  ;  Physician  to 

Bellevue  Hospital. 

J.  WILLISTON  WRIGHT,  M.D.,  Professor  of 
Surgery  ;  Surgeon  to  Bellevue  Hospital. 

WM.  MECKLENBURG  POLK,  MB,  Professor 
of  Obstetrics  and  Diseases  of  Women  and  Chil- 
dren ;  Physician  to  Bellevue  Hospital,  and  to 
Emergency  Lying-in  Hospital. 

LEWIS  A.  STIMSON,  M.D  ,  Professor  of  Anat- 
omy ;  Professor  of  Clinical  Surgery  ;  Surgeon  to 
Bellevue  and  Presbyterian  Hospitals. 

RUDOLPH  A.  WITTHAUS,  M.D.,  Professor  of 
Chemistry  and  Physics. 

WM.  G.  THOMPSON,  M.D.,  Professor  of  Physi- 
ology. 

STEPHEN  SMITH,  M.D.,  Professor  of  Clinical 
Surgery  ;  Surgeon  to  Bellevue  Hospital. 

A.  E.  MACDONALD,  LL.D.,  M.D.,  Professor  of 
Medical  Jurisprudence  and  Psychological  Medi- 
cine ;  General  Superintendent  of  the  New  York 
City  Asylums  for  the  Insane. 


HERMANN  KNAPP,  M.D.,  Professor  of  Oph- 
thalmology ;  Surgeon  to  the  New  York  Ophthal- 
mic and  Aural  Institute. 

FANEUIL  D.  WEISSE,  M.D.,  Professor  of  Prac- 
tical and  Surgical  Anatomy  ;  Surgeon  to  Work- 
house Hospital,  B.  I. 

HENRY  G.  PIFFARD,  M.D.,  Clinical  Professor 
of  Dermatology  ;  Consulting  Surgeon  to  Charity 
Hospital. 

F.  R.  S.  DRAKE,  M.D.,  Clinical  Professor  of 
Medicine  ;  Physician  to  Bellevue  Hospital. 

JOSEPH  E.  WINTERS,  M.D.,  Clinical  Professor 
of  Diseases  of  Children. 

PRINCE  A.  MORROW,  M.D.,  Clinical  Professor 
of  Venereal  Diseases  ;  Surgeon  to  Charity  Hos- 
pital. 

WILLIAM  C.  JARVIS,  M.D.,  Clinical  Professor 
of  Laryngology. 

LAURENCE  JOHNSON,  M.D.,  Professor  of  Medi- 
cal Botany ;  Visiting  Physician  to  Randall's 
Island  Hospital. 

WESLEY  M.  CARPENTER,  M.D  ,  Clinical  Pro- 
fessor of  Medicine. 

HARRY  P.  LOOMIS,  M.D.,  Adjunct  Professor  of 
Pathology,  and  Director  of  the  Pathological 
Laboratory. 

S.  C.  BLAISDELL,  M.D.,  Demonstrator  of 
Anatomy. 

MAURICE  N.  MILLER,  M.D.,  Director  of  the 
Histological  Laboratory. 


The  Preliminary  Session  will  begin  on  Wednesday,  September  21,  1887,  and  end  October  4,  1887. 
It  will  be  conducted  on  the  same  plan  as  the  Regular  Winter  Session. 

The  Regular  Winter  Session  will  begin  October  5,  1887,  and  end  about  March,  1888.  The  plan 
of  Instruction  consists  of  Didactic  and  Clinical  Lectures,  recitations,  and  laboratory  work  in  all  subjects 
in  which  it  is  practicable. 

Laboratories  and  Section  Teaching.— The  complete  remodelling  of  the  College  building,  and  the 
addition  of  the  new  "Loomis  Laboratory  "  adjoining,  will  be  completed  for  the  opening  of  the  session 
of  1887-88.  They  will  afford  greatly  increased  laboratory  accommodations  in  the  departments  of 
Biology,  Pathology,  Physiology,  Chemistry,  and  Physics.  A  new  amphitheatre  and  a  new  lecture  room 
have  been  provided,  as  well  as  adequate  facilities  for  Section  teaching,  in  which  the  material  from  the 
College  Dispensary  will  be  utilized. 

Two  to  five  Didactic  Lectures  and  two  or  more  Clinical  Lectures  will  be  given  each  day  by  members 
of  the  Faculty.  In  addition  to  the  ordinary  clinics,  special  clinical  instruction,  without  additional  expense, 
will  be  given  to  the  candidates  for  graduation  during  the  latter  part  of  the  Regular  Session.  For  this 
purpose  the  candidates  will  be  divided  into  sections  of  twenty-five  members  each.  All  who  desire  to 
avail  themselves  of  this  valuable  privilege  must  give  in  their  names  to  the  Dean  during  the  first  week. 
At  these  special  clinics  students  will  have  excellent  opportnnities  to  make  and  verify  diagnoses,  and 
watch  the  effects  of  treatment.  They  will  be  held  in  the  Wards  of  the  Hospitals  and  at  the  Public  and 
College  Dispensaries. 

Each  of  the  seven  Professors  of  the  Regular  Faculty,  or  his  assistant,  will  conduct  a  recitation  on  his 
subject  one  evening  each  week.  Students  are  thus  enabled  to  make  up  for  lost  lectures  and  prepare 
themselves  properly  for  their  final  examinations  without  additional  expense. 

The  Spring  Session  will  begin  about  the  middle  of  March  and  end  the  last  week  in  May.  The  daily 
Clinics  and  Special  Practical  Courses  will  be  the  same  as  in  the  Winter  Session,  and  there  will  be  Lectures 
on  Special  Subjects  by  Members  of  the  Faculty. 

It  is  supplementary  to  the  Regular  Winter  Session.  Nine  months  of  continued  instruction  are  thus 
secured  to  all  students  of  the  University  who  desire  a  thorough  course. 

FEES. 

For  course  of  Lectures   8140.00 

Matriculation   5.00 

Demonstrator's  Fee,  including  material  for  dissection   10.00 

Final  Examination  Fee   30.00 

For  further  particulars  and  circulars  address  the  Dean, 

PROP.  CHAS.  INSLEE  PARDEE,  M.D., 

University  Medical  College,  410  Eavt  26t?i  St.,  New  York  City. 


University  of  Pennsylvania 

DEPARTMENT  OF  MEDICINE. 

Thirty-sixth  Street  and  Woodland  Avenue,  Philadelphia. 
One  Hundred  and  Twenty-second  Annual  Session,  1887-88. 


Students  who  have  not  received  a  collegiate  degree,  or  who  do  not  present  the  evidence  of  previous 
education  referred  to  in  the  Catalogue,  are  required  to  pass  a  preliminary  examination  in  English  and 
Physics,  for  details  of  which  see  Catalogue. 

Attendance  is  required  upon  three  winter  courses  of  graded  instruction,  seven  months  in  duration, 
and  consisting  of  didactic  lectures,  daily  clinical  lectures,  and  practical  work  in  laboratories  and 
hospitals. 

A  voluntary  fourth  year,  almost  purely  practical,  has  been  established,  for  particulars  of  which 
see  Catalogue. 

PROFESSORS. 


WILLIAM  PEPPER,  M.D.,  LL.D.,  Provost. 
HENRY  H.  SMITH,  M.D  ,  Surgery,  Emeritus. 

ALFRED  STILLE,  M,D.,  LL  D.,  Theory  and 
Practice  of  Medicine,  Emeritus. 

HARRISON  ALLEN,  M.D.,  Physiology,  Emeri- 
tus. 


JOSEPH  LEIDY,  M.D.,  LL.D.,  Anatomy. 
RICHARD  A.  F.  PENROSE,  M.D.,  LL.D.,  Ob- 
stetrics 

D.  HAYES  AGNEW,  M.D.,  LL  D.,  Surgery  and 

Clinical  Surgery. 
WILLIAM  PEPPER,  M.D  ,  LL.D.,  Theory  and 
Practice  of  Medicine,  and  Clinical  Medicine. 
M.D. 


WILLIAM  GOODELL 

cology. 
JAMES  TYSON,  M.D., 

Morbid  Anatomy. 
HORATIO  C.  WOOD,  M.D.,  LL.D.,  Materia  Med 

ica,  Pharmacy  and  General  Therapeutics. 


Clinical  Gynae- 
General  Pathology  and 


ROLAND  G.  CURT  IN,  M.D 
cal  Diagnosis. 


Lecturer  on  Physi- 
CHARLES  K.  MILLS,  M.D.,  Lecturer  on  Mental 


ADOLPH  W.  MILLER,  M.D.,  Demonstrator  of 
Practical  Pharmacy  and  Lecturer  on  Materia 
Medica  and  Pharmacy. 

DE  FORREST  WILLARD,  M.D.,  Lecturer  on 
Orthopaedic  Surgery. 

JOHN  MARSHALL,  M.D.,  Nat.  Sc.  D.,  Demon- 
strator of  Practical  Anatomy. 

J.  WILLIAM  WHITE,  M.D.,  Demonstrator  of 
Surgery. 

HARRY  R.  WHARTON,  M  D  ,  Instructor  in 
Clinical  Surgery. 

JOHN  B.  DEAVER,  M.D.,  Demonstrator  of  Ana- 
tomy 

HENRY  F.  FORMAD,  M.D.,  Demonstrator  of 

Pathology  and  Morbid  Anatomy,  and  Lecturer 

on  Experimental  Pathology. 
GEORGE  A.  PIERSOL,  M.D.,  Demonstrator  of 

Normal  Histology. 
RICHARD  H.  HARTE,  M.D.,  Demonstrator  of 

Osteology. 

GEORGE  E.  De  SCHWEINITZ,  M  D.,  Prosector 
to  the  Professor  of  Anatomy. 

SAMUEL  D.  RISLEY,  M.D.,  Instructor  in  Oph- 
thalmology. 

W.  M.  ZIEGLER,  M.D  ,  Instructor  in  Otology. 
CARL  SEILER,  M.D.,  Instructor  in  Laryngology. 
FRANCIS  X.  DERCUM,  M.D.,  Instructor  in  Ner- 
vous Diseases. 


THEODORE  G.  WORMLEY,  M.D.,  LL.D.,  Chem- 
istry and  Toxicology. 
JOHN  ASHHURST,  Jr  ,  M.D.,  Clinical  Surgery. 
WILLIAM  OSLER,  M.D.,  Clinical  Medicine. 
EDWARD  T.  REICHERT,  M.D.,  Physiology. 
WILLIAM  F.  NORRIS,  M.D.,  Ophthalmology. 

GEORGE  STRAWBRIDGE,  M.D.,  Clinical  Pro- 
fessor of  Diseases  of  the  Ear. 
HORATIO  C.  WOOD,  M.D.,  Nervous  Diseases. 
LOUIS  A.  DUHRING,  M.D.,  Dermatology. 
LOUIS  STARR,  M.D.,  Paediatrics. 
EDWARD  T.  BRUEN,  M.D.,  Assistant  Professor 

of  Physical  Diagnosis. 
JOHN  J.  REESE,  M.D.,  Medical  Jurisprudence 

and  Toxicology. 
J.  WM.  WHITE,  M.D.,  Genito-Urinary  Diseases. 
N.  ARCHER  RANDOLPH,  M  B,  Hygiene. 
OTHER  INSTRUCTORS. 

J.  HENDRIE  LLOYD,  M.D.,  Instructor  in  Elec- 
tro-Therapeutics. 
A.  SYDNEY  ROBERTS,  M  D.,  Instructor  in  Orth- 
opaedic Surgery. 
HENRY  W.  STELWAGON,  M.D.,  Instructor  in 

Dermatology. 
WILLIAM   L.  TAYLOR,  M.D.,  Instructor  in 

Clinical  Gynaecology. 
THOMAS  R.  NEILSON,  M.D.,  f  Assist.  Demonst. 
EDMUND  W.  HOLMES,  M.D.,  X    of  Anatomy 

G.  G.  DAVIS,  M.D.,  Assistant  Demonstrator  of 
Surgery. 

ALBERT  L.  A.  TOBOLDT,  M  D.,  Assistant  De- 
monstrator of  Practical  Pharmacy. 

WILLIAM  A.  EDWARDS,  M.D.,  f  Instructors  in 
JUDSON  DALAND,  M.D.,  t  Clinical  Med. 

W.  FRANK  HAEHNLEN,  M.D.,  Assistant  De- 
monstrator of  Normal  Histology. 
HOBART  A.  HARE,  M.D.,  Demonstrator  of  Ex- 
perimental Therapeutics. 
JOHN  K.  MITCHELL,  M.D.,  Instructor  in  Clini- 
cal Medicine. 
EDWARD  MARTIN,  M.D.,  Instructor  in  Opera- 
tive Surgery  and  Demonstrator  of  Anatomy. 

GEORGE  H.  CHAMBERS,  M.D.,  Assistant  De- 
monstrator of  Normal  Histology. 

JAMES  EL.  YOUNG,  M.D.,  Assistant  Demonstra- 
tor of  Surgery. 
DAVID  D.  RICHARDSON,  M.D.,  Assistant  De- 
monstrator of  Anatomy. 


The  Lectures  of  the  Winter  Session  of  1887-88  will  begin  on  Monday,  October  3d. 
The  Preliminary  Course  will  begin  on  Monday,  September  19th. 

In  the  Spring  Months  the  Laboratories  of  Chemistry,  Histology,  Physiology  and  Pathology  are  open, 
and  clinical  instruction  is  continued. 

Fees  in  Advance  — Matriculation,  $5.  For  each  Session,  including  dissection,  operating,  and 
bandaging,  $150.    No  graduation  fee. 

For  Catalogue  giving  full  particulars,  address 

JAMES  TYSON,  M.D.,  Secretary, 

Philadelphia,  Pa. 


MEDICAL  DEPARTMENT 


or  THE 


Tulane  University  of  Louisiana 

(Formerly,  1847-1884,  The  University  of  Louisiana.) 


FACULTY. 


SAMUEL  LOGAN,  M.D  , 
Emeritus  Professor  of  Anatomy  and  Clinical 
Surgery. 

T.  G.  RICHARDSON,  M.D., 
Professor  of  General  and  Clinical  Surgery. 

STANFORD  E.  CHAILLE,  M.D., 
Professor  of  Physiology  and  Pathological 
Anatomy. 

JOSEPH  JONES,  M.D., 
Professor  of  Chemistry  and  Clinical  Medicine. 


ERNEST  S.  LEWIS,  M.D., 
Professor  of  Obstetrics  and  Diseases  of  Women 
and  Children. 
JOHN  B.  ELLIOTT,  M.D., 
Professor  of  the  Theory  and  Practice  of  Medicine 
and  Clinical  Medicine. 
EDMOND  SOUCHON,  M.D., 
Professor  of  Anatomy  and  Clinical  Surgery. 
A.  B.  MILES,  M  D., 
Professor  of  Materia  Medica,  Therapeutics  and 
Hygiene. 


Lecturer  on  Diseases  of  the  Eye  and  Ear,  S.  D.  KENNEDY,  M.D. 
Lecturer  on  Dermatology,  HY.  WM.  BLANC,  M.D. 
Demonstrator  of  Anatomy,  RUDOLPH  MATAS,  M.D. 
Assistant  Demonstrator  of  Anatomy,  A.  McSHANE,  M.D. 


The  next  annual  session  of  this  Department,  now  in  the  fifty -fourth  year  of  its  existence,  will  begin 
on  Monday,  October  17,  1887,  and  end  on  Saturday,  March  24,  1888.  The  first  four  weeks  of  the  term 
will  be  devoted  exclusively  to  Clinical  Medicine,  Surgery,  Obstetrics,  and  Gynecology,  in  the  wards 
and  amphitheatre  of  the  Charity  Hospital ;  to  practical  Chemistry  in  the  Chemical  Laboratory  ;  and  to 
practical  Anatomy  in  the  spacious  and  well-ventilated  anatomical  rooms  of  the  University. 

The  means  for  practical  instruction  are  unsurpassed  in  the  United  States,  and  special  attention  is 
called  to  the  superior  opportunities  presented  for 

CLINICAL  INSTBUCTION. 

The  Professors  of  the  Medical  Department  are  given,  by  law,  the  use  of  the  great  Charity  Hospital 
as  a  school  of  practical  instruction,  and  medical  students  are  admitted  without  payment  of  any  hospital 
fees.  The  Charity  Hospital  contains  seven  hundred  beds,  the  number  of  patients  annually  admitted 
varies  from  seven  to  eight  thousand,  and  the  number  of  visiting  patients  exceeds  thirteen  thousand.  Its 
advantages  for  practical  study,  and  especially  of  the  diseases  of  the  Southwest,  are  unequalled  by  any 
similar  institution  in  this  country.  The  Medical,  Surgical  and  Obstetrical  Wards  are  visited  daily  by 
the  respective  Professors,  and  all  students  are  expected  to  attend  and  to  familiarize  themselves,  at  the 
bedside  of  the  patients,  with  the  diagnosis  and  treatment  of  all  forms  of  diseases  and  injury.  Regular 
lectures  are  also  given  daily  from  8%  to  11  a.  m.  in  the  Amphitheatre  of  the  Hospital,  either  on  Clini- 
cal Medicine,  or  Clinict.1  Surgery,  or  Pathological  Anatomy,  and  this  thorough  course  of  practical 
clinical  instruction  is  followed  by  the  usual  didactic  lectures  in  the  three  ample  lecture-rooms  of  the 
Medical  Department. 

The  administrators  of  the  Charity  Hospital  elect  annually,  by  competitive  examination  in  March, 
fourteen  Resident  Students,  who  are  given  board  and  lodging  free  of  charge. 


TEEMS  PEE  ANNUAL  SESSION. 

let  Session.  2d  Sessio)i. 

Matriculation  Ticket  $5  00   

General  Ticket  of  all  Professors                                   140  00  .  $140  00 

Ticket  of  Demonstrator  of  Anatomy    ....     10  00  10  Oo 

Diploma  Fee  (once  only  when  graduated)    30  00 

Total  $155  00  $180  00 

After  the  total  fees  (for  two  full  courses)  of  §305,  as  above,  have  been  paid,  no  fees  (except  the  $30 
Diploma  fee)  are  required  for  subsequent  courses,  however  numerous.  The  payment  of  the  total  $335 
may  be  distributed  over  a  three  years'  cour.e,  as  follows,  viz.  :  $105  the  first  year,  $100  the  second 
year,  and  $130  the  third  year.    All  fees  are  payable  in  advance. 

Students  who  have  attended  and  paid  for  two  full  courses  of  lectures,  the  last  of  which  was  in  this 
institution,  are  entitled  to  attend  thereafter  without  charge. 

Candidates  for  graduation  are  required  to  be  twenty-one  years  of  age,  to  have  studied  three  years, 
to  have  attended  two  courses  of  lectures,  and  to  pass  a  satisfactory  examination. 

Graduates  of  other  respectable  schools  are  admitted  upon  payment  of  the  Matriculation  and  half 
Lecture  Fees.  They  cannot,  however,  obtain  the  Diploma  of  the  University  without  passing  the  regu- 
lar examination,  and  paying  the  usual  Graduation  Fee. 

As  the  practical  advantages  here  offered  for  a  thorough  acquaintance  with  all  the  branches  of 
medicine  and  surgery  are  unsurpassed  by  those  possessed  by  the  beet  schools  of  New  York  and  Phila- 
delphia, the  same  fees  are  charged. 

For  further  information  and  circular,  address 

Prof.  S.  E.  CHAILLE,  Dean, 


P.  0.  Drawer  261,  New  Orleans,  La. 


The  Jefferson  Medical  College 

OF  PHILADELPHIA. 


The  Sixty-third  Session  of  the  Jefferson  Medical  College  will  begin  October  1,  1887, 
and  will  continue  until  the  end  of  March,  1888.  Preliminary  Lectures  will  be  held  from 
19th  of  September. 

PROFESSORS. 


J.  M.  DA  COSTA,  M.D.,  LL.D., 
Practice  of  Medicine. 

ROBERTS  BARTHOLOW,  M.D.,  LL.D., 
Materia  Medica,  General  Therapeutics  and 
Hygiene. 

HENRY  C.  CHAPMAN,  M.D., 
Institutes  of  Medicine  and  Medical  Jurisprudence. 

SAMUEL  W.  GROSS,  M.D.,  LL.D., 
Principles  of  Surgery  and  Clinical  Surgery. 

JOHN  H.  BRINTON,  M  D., 
Practice  of  Surgery  and  Clinical  Surgery. 


THEOPHILUS  PARVIN,  M.D.,  LL.D., 

Obstetrics  and  Diseases  of  Women  and  Children. 

J.  W.  HOLLAND,  31.  D, 
Medical  Chemistry  and  Toxicology . 

WILLIAM  S.  FORBES,  M.D., 
General,  Descriptive  and  Surgical  Anatomy. 


WILLIAM  THOMSON,  M.D., 
Honorary  Professor  of  Ophthalmology. 

MORRIS  LONGSTRETH,  M.D., 
Lecturer  on  Pathological  Anatomy. 


The  Faculty  successfully  conducts  a  thorough  system  of  Practical  Laboratory  Instruction  in  all  the 
Departments. 

The  Fall  Term  is  preliminary  to  the  Lectures  of  the  Winter  Coursk,  and  is  occupied  with  topics 
supplementary  to  them. 

Clinical  Instruction  is  given  daily  in  the  Hospital  of  the  Jefferson  Medical  College  throughout 

the  year  by  Members  of  the  Faculty,  and  by  the  Hospital  Staff. 


The  Annual  Announcement,  giving  full  particulars,  will  be  sent  on  application  to 

J.  W.  HOLLAND,  M.D.,  Dean. 


Bellevue  Hospital  Medical  College, 

CITY  OF  NEW  YOKK. 
Sessions  of  1887-88. 


The  Regular  Session  begins  on  Wednesday,  September  21, 1887,  and  ends  about 
the  middle  of  March,  1888.  During  this  Session,  in  addition  to  the  regular  didactic 
lectures,  two  or  three  hours  are  daily  allotted  to  clinical  instruction.  Attendance  upon 
at  least  two  regular  courses  of  lectures  is  required  for  graduation. 

The  Spring  Session  consists  of  recitations,  clinical  lectures  and  exercises,  and 
didactic  lectures  on  special  subjects.  This  Session  begins  about  the  middle  of  March 
and  continues  until  the  middle  of  June.  During  the  Session,  daily  recitations  in  all 
the  departments  are  held  by  a  corps  of  Examiners  appointed  by  the  Faculty. 

The  Carnegie  Laboratory  is  open  during  the  collegiate  year,  for  instruction  in 
microscopical  examinations  of  urine,  practical  demonstrations  in  medical  and  surgical 
pathology,  and  lessons  in  normal  histology  and  pathology,  including  bacteriology. 

For  the  annual  Circular  and  Catalogue,  giving  requirements  for  graduation  and 
other  information,  address  Prof.  Austin  Flint,  Secretary,  Bellevue  Hospital  Medical 
College,  foot  of  East  26th  Street,  New  York  City. 


LEA  BROTHERS  &  CO.'S 

(Late  HENRY  C.  LEA'S  SON  &  CO.) 

CLASSIFIED  CATALOGUE 

OF 

MEDICAL  AND  SURGICAL 

PUBLICATIONS. 


In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following  pages, 
the  publishers  would  state  that  no  pains  are  spared  to  secure  a  continuance  of  the  confi- 
dence earned  for  the  publications  of  the  house  by  their  careful  selection  and  accuracy  and 
finish  of  execution. 

The  large  number  of  inquiries  received  from  the  profession  for  a  finer  class  of  bindings  than  is 
usually  placed  on  medical  books  has  induced  us  to  put  certain  of  our  standard  publications  in 
half  Russia;  and,  that  the  growing  taste  may  be  encouraged,  the  prices  have  been  fixed  at  so  small 
an  advance  over  the  cost  of  sheep  as  to  place  it  within  the  means  of  all  to  possess  a  library  that 
shall  have  attractions  as  well  for  the  eye  as  for  the  mind  of  the  reading  practitioner. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works  not 
kept  in  stock.  Where  access  to  bookstores  is  not  convenient  books  will  be  sent  by  mail 
postpaid  on  receipt  of  the  price,  and  as  the  limit  of  mailable  weight  has  been  removed,  no 
difficulty  will  be  experienced  in  obtaining  through  the  post-office  any  work  in  this  cata- 
logue. No  risks,  however,  are  assumed  either  on  the  money  or  on  the  books,  and  no  pub- 
lics tions  but  our  own  are  supplied,  so  that  gentlemen  will  in  most  cases  find  it  more  con- 
venient to  deal  with  the  nearest  bookseller. 

LEA  BROTHEES  &  CO. 
Nos.  706  and  708  Sansom  St.,  Philadelphia,  June,  1887. 

PROSPECTUS  FOR  1887. 

The  American  Journal  of  the  Medical  Sciences. 

Quarterly ;  300-350  pages,  with  illustrations.    Price,  $5.00  per  annum. 


WITH  the  year  1886  The  American  Journal  of  The  Medical  Sciences  became 
in  Great  Britain  the  recognized  organ  of  the  profession — a  position  similar  to 
that  occupied  by  it  in  America  for  sixty-six  years.  On  its  announcement,  this  project  for 
an  international  journal  was  welcomed  abroad  with  acclamation,  and  one  hundred  and 
thirty-five  of  the  foremost  English  practitioners  authorized  the  use  of  their  names 
as  contributors  in  order  to  aid  in  extending  over  their  country  the  benefits  which  Ameri- 
can medicine  has  enjoyed  from  the  existence  of  The  Journal  during  two  generations' 
This  friendly  challenge  was  accepted  by  an  almost  equal  number  of  Americans,  to 
whose  proved  ability  this  country  can  well  afford  to  entrust  her  reputation. 

In  thus  becoming  the  medium  of  communication  between  the  two  nations  dist  inguished 
above  all  others  by  the  practical  character  of  their  labors,  The  Journal  undoubt- 
edly forms  the  most  efficient  factor  in  medical  progress  which  the  world  has  yet  seen. 
Already  this  generous  spirit  of  rivalry  has  proved  that  the  ample  space  devoted  to 
Original  Articles  will  continue  to  be  filled  with  a  series  of  contributions  unapproachable 
in  value. 


2   Lea  Brothers  &  Co.'s  Periodicals — Am.  Journal,  Medical  News. 


THE  AMERICAN  JOURNAL  of  the  MEDICAL  SCIENCES. 

^   •  (Continued  from  first  page.) 

But  it  is  not  only  in  the  Original  Department  that  the  Journal  of  the  future  will  seek 
to  eclipse  all  its.  efforts  in  the  past.  The  mass  of  contributions  to  medical  literature  and 
science  increases  with  such  rapidity,  that  if  the  reader  is  to  keep  abreast  with  them 
the  matter  must  be  carefully  sifted,  and  arranged  so  as  to  enable  him  to  grasp  it 
understandingly  with  the  least  possible  expenditure  of  time.  In  the  Bibliographical 
Department,  therefore,  separate  reviews  are  devoted  only  to  works  of  exceptional 
importance^  As  a  rule,  new  books  are  considered  in  groups  of  cognate  subjects,  the 
jrlvieMbr  setting  forth  tersely  the  merits  of  the  individual  volumes  with  a  condensed 
%ll!te*ftiht  of  the  views  of  the  authors.  In  this  manner  the  reader  is  kept  advised  of 
the  products  of  the  press  in  the  most  convenient  manner. 

A  similar  plan  is  adopted  in  the  Quarterly  Summary  of  Progress.  The  various 
branches  of  medical  science  have  been  assigned  to  the  following  gentlemen,  who  will 
furnish  well-digested  resumes  of  progress,  paying  special  attention  to  clinical  application : 
Anatomy,  George  D.  Thane,  M.  E.  C.  S.;  Physiology,  Gerald  F.  Yeo,  M.  D.;  Materia 
Medica,  Therapeutics  and  Pharmacology,  Koberts  Bartholow,  M.  D.,  LL.  D. ;  Medicine, 
<WifHam  Osier,  M.D.;  Surgery,  in  America,  E.  J.  Hall,  M.  D.;  in  Europe,  Frederick 
■#*®*es,  F.  E.  C.  S.;  Ophthalmology,  L.  Webster  Fox,  M.  D. ;  Otology,  Charles  H.  Burnett, 
MsD.;  Laryngology,  J.  Solis  Cohen,  M.  D.;  Dermatology,  Louis  A.  Duhring,  M.  D.,  and  H. 
W.  Stel wagon,  M.  t>. ;  Midwifery  and  Gynecology,  D.  Berry  Hart,  M.  D.;  Jurisprudence, 
J^atthew  Hay,  M.  D.;  Public  Health,  Shirley  F.  Murphy,  M.  E.  C.  S. 
^  f  The  publishers  feel  an  honest  pride  in  thus  being  the  means  of  bringing  together  the 
professions  of  the  two  great  English-speaking  peoples,  and  in  laying  before  them  a  period- 
ical which  must  be  universally  recognized  as  marking  a  new  era  in  medical  progress. 
Relieving  that  it  will  be  regarded  as  indispensable  by  all  intelligent  physicians  on  both 
sides  of  the  Atlantic,  they  feel  themselves  warranted,  by  the  expectation  of  a  large  in- 
crease in  circulation,  in  maintaining  the  present  very  moderate  subscription  price,  not- 
withstanding the  greatly  augmented  expenditure  entailed  by  the  change. 

The  J ottrnal  will  continue  to  be  published  quarterly,  as  heretofore,  on  the  first  of 
J anuary,  April,  July  and  October. 

Price,  FIVE  DOLLARS  Per  Annum,  in  Advance. 


THE  MEDICAL  NEWS. 

A  National  Weekly  Periodical,  containing  28  to  32  Quarto  Pages 

in  Each  Issue. 

THE  continually  increasing  appreciation  of  The  Medical  News  by  the  profession 
throughout  the  country,  is  a  most  gratifying  recognition  of  the  policy  pursued  by 
the  managers  of  this  journal  in  their  unceasing  efforts  to  enhance  its  value  to  the 
practitioner. 

Possessing  a  most  efficient  organization  The  News  unites  the  best  features  of  the 
medical  magazine  and  newspaper.  Its  large  and  able  Editorial  Staff  discusses  in  each 
issue  the  important  topics  of  the  day  in  a  thoughtful  and  scholarly  manner,  while  its 
corps  of  qualified  reporters  and  correspondents,  covering  every  medical  centre,  insures 
that  its  readers  shall  be  promptly  and  thoroughly  posted  upon  all  matters  of  interest  in 
the  world  of  medicine.  On  account  of  the  position  conceded  to  The  News,  it  has  become 
the  medium  chosen  by  the  leading  minds  of  the  profession  for  the  publication  of  their 
most  important  contributions  to  medical  science.  The  valuable  instruction  afforded  in 
Clinical  Lectures,  and  the  rich  experience  gained  in  the  leading  Hospitals  of  the  world 
are  constantly  laid  before  the  readers  of  The  News,  while  prompt  and  authentic  reports 
of  Society  Proceedings  are  received  from  special  reporters  in  various  sections  of  the 
country  by  mail  and  Telegraph.  In  the  pages  devoted  to  the  progress  of  Medical  Science 
are  found  early  notes  of  all  important  advances,  gleaned  from  the  principal  journals 
of  both  hemispheres.  Ample  space  is  devoted  to  Eeviews,  News  Items,  Correspondence 
and  Notes  and  Queries  In  short,  every  branch  of  medicine  is  adequately  represented  in 
The  News,  and  the  details  of  plan  and  typography  have  been  carefully  studied  in  order 
to  economize  the  time  and  secure  the  comfort  of  the  reader  in  every  possible  way. 
Price,  FIVE  DOLLARS  Per  Annum,  in  Advance. 


COMMUTATION  RATE. 

To  subscribers  paying  in  advance  for  1887 : — 
American  Journal  of  the  Medical  Sciences  (quarterly)  \  To  one  address  for  $9.00 
The  Medical  News  (weekly)  J    per  annum. 

SPECIAL  OFFERS. 

A dvance- paying  subscribers  to  either  or  both  of  the  above-named  periodicals  may  take 
advantage  of  any  one  of  the  following  offers : 

(1).  The  Medical  News  Visiting  List  for  1887,  dated,  either  for  30  patients 
per  week  (1  vol.),  or  for  60  patients  (2  vols.),  or  for  90  patients  (3  vols.),  will  be  sent 


Lea  Brothers  &  Co.'s  Publications — Period.,  Manuals. 


3 


post-paid  on  receipt  of  75  cents  per  volume  (regular  price  $1.25).  (2).  The  Yeae-Book 
of  Treatment  for  1886  will  be  sent  on  receipt  of  75  cents  (regular  price  $1.25).  (3), 
An  advance  remittance  of  $10  will  procure  The  News  and  The  Journal  for  one  year, 
together  with  any  one  volume  of  The  Medical  News  Visiting  List  and  The  Year- 
book of  Treatment  for  1886,  as  offered  above.  Subsequent  volumes  of  The  Medical 
News  Visiting  List  may  be  procured  by  advance- paying  subscribers  for  75  cents  each 
(regular  price  $1.25).    Thumb-letter  Index  for  quick  use,  25  cents  additional. 

Subscribers  can  obtain,  at  the  close  of  each  volume,  cloth  covers  for  The  Journal  (one 
annually),  and  for  The  News  (one  annually),  free  by  mail,  by  remitting  Ten  Cents  for  the 
Journal  cover,  and  Fifteen  Cents  for  the  News  cover. 


The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn  to 
the  order  of  the  undersigned ;  where  these  are  not  accessible,  remittances  for  subscriptions 
may  be  sent  at  the  risk  of  the  publishers  by  forwarding  in  registered  letters.  Address, 

LEA  BBOTKERS  &  CO.,  706  and  708  Sansom  Street,  Philadelphia. 


THE  MEDICAL  NEWS  VISITING  LIST  FOB  1887. 

Containing  Calendar  for  two  years.  Obstetric  diagrams.  Scheme  of  Dentition.  Tables 
of  weights  and  measures  and  comparative  scales.  Instructions  for  examining  the  urine. 
List  of  disinfectants.  Table  of  eruptive  fevers.  Lists  of  new  remedies  and  remedies 
not  generally  used,  Incompatibles,  Poisons  and  Antidotes.  Artificial  respiration.  Table  of 
doses,  prepared  to  accord  with  the  last  revision  of  the  U.  S.  Pharmacopoeia,  an  extended 
table  of  Diseases  and  their  remedies,  and  directions  for  Ligation  of  Arteries.  Blanks 
for  all  records  of  practice  and  Erasable  tablet.  Handsomely  bound  in  limp  Morocco,  with 
tuck,  pencil,  rubber  and  catheter  scale. 

In  response  to  numerous  requests,  The  Medical  News  Visiting  List  for  1887  is 
issued  in  three  sizes,  viz. :  Dated,  for  30  patients  per  week,  1  vol. ;  dated,  for  60  patients, 
2  vols.;  dated,  for  90  patients,  3  vols.;  Price  per  volume,  $1.25.  Also,  furnished  with 
Ready  Reference  Thumb-letter,  Index  for  quick  use,  25  cents  additional.  For  special 
offers,  including  Visiting  List,  see  above. 

THE  MEDICAL  NEWS  PHYSICIANS9  LEDGER,* 

Containing  400  pages  of  fine  linen  "  ledger  "  paper,  ruled  so  that  all  the  accounts  of  a 
large  practice  may  be  conveniently  kept  in  it,  either  by  single  or  double  entry,  for  a  long 
period.  Strongly  bound  in  leather,  with  cloth  sides,  and  with  a  patent  flexible  back, 
which  permits  it  to  lie  perfectly  fiat  when  opened  at  any  place.  Price,  $5.00.  Also, 
a  small  special  lot  of  same  Ledger,  with  300  pages.    Price,  $4.00. 


HABTSHOMNE,  HENRY,  A.  31.,  M.  D.,  LL.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thoroughly  revised  and  greatly  improved.    In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.    Cloth,  $4.25 ;  leather,  $5.00. 

industry  and  energy  of  its  able  editor.— Boston 
Medical  and  Surgical  Journal,  Sept.  3,  1874. 

We  can  say  with  the  strictest  truth  that  it  is  the 
best  work  of-  the  kind  with  which  we  are  ac- 
quainted. It  embodies  in  a  condensed  form  all 
recent  contributions  to  practical  medicine,  and  is 
therefore  useful  to  every  ousy  practitioner  through- 
out our  country,  besides  being  admirably  adapted 
to  the  use  of  students  of  medicine.  The  book  is 
faithfully  and  ably  executed.— Charleston  Medical 
Journal,  April,  1875. 


The  object  of  this  manual  is  to  afford  a  conven- 
ient work  of  reference  to  students  during  the  brief 
moments  at  their  command  while  in  attendance 
upon  medical  lectures.  It  is  a  favorable  sign  that 
it  has  been  found  necessary,  in  a  short  space  of 
time,  to  issue  a  new  and  carefully  revised  edition. 
The  illustrations  are  very  numerous  and  unusu- 
ally clear,  and  each  part  seems  to  have  received 
its  due  share  of  attention.  We  can  conceive  such 
a  work  to  be  useful,  not  only  to  students,  but  to 
practitioners  as  well.  It  reflects  credit  upon  the 


NEILL9  JOHN,  M.  D.9  and  SMITH,  E.  G.,  M.  D., 

Late  Surgeon  to  the  Penna.  Hospital.  Prof,  of  the  Institutes  of  Med.  in  the  Univ.  of  Penna. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medical 
Science,  for  the  use  and  examination  of  Students.  A  new  edition,  revised  and  improved. 
In  one  large  royal  12mo.  volume  of  974  pages,  with  374  woodcuts.  Cloth,  $4 ;  leather,  $4.75. 

LUDLOW,  J.L.,M.D., 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics.  To  whicn 
is  added  a  Medical  Formulary.  3d  edition,  thoroughly  revised,  and  greatly  enlarged.  In 
one  12mo.  volume  of  816  pages,  with  370  illustrations.    Cloth,  $3.25;  leather,  $3.75. 

The  arrangement  of  this  volume  in  the  form  of  question  ami  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


4 


Lea  Brothers  &  Co.'s  Publications — Dictionaries. 


DUNGLISON,  MOBLEY,  M.I>., 

Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON ;  A  Dictionary  of  Medical  Science :  Containing 

a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulae  for  Officinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Kichard  J.  Dunglison,  M.  D.  In  one  very  large  and 
handsome  royal  octavo  volume  of  1139  pages.  Cloth,  $6.50 ;  leather,  raised  bands,  $7.50 ; 
very  handsome  half  Eussia,  raised  bands^  $8. 

The  object  of  the  author,  from  the  outset,  has  not  been  to  make  the  work  a  mere  lexi- 
con or  dictionary  of  terms,  but  to  afford  under  each  word  a  condensed  view  of  its  various 
medical  relations,  and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of 
medical  science.  Starting  with  this  view,  the  immense  demand  which  has  existed  for  the 
work  has  enabled  him,  in  repeated  revisions,  to  augment  its  completeness  and  usefulness, 
until  at  length  it  has  attained  the  position  of  a  recognized  and  standard  authority  wherever 
the  language  is  spoken.  Special  pains  have  been  taken  in  the  preparation  of  the  present 
edition  to  maintain  this  enviable  reputation.  The  additions  to  the  vocabulary  are  more 
numerous  than  in  any  previous  revision,  and  particular  attention  has  been  bestowed  on  the 
accentuation,  which  will  be  found  marked  on  every  word.  The  typographical  arrangement 
has  been  greatly  improved,  rendering  reference  much  more  easy,  and  every  care  has  been 
taken  with  the  mechanical  execution.  The  volume  now  contains  the  matter  of  at  least 
four  ordinary  octavos. 


About  the  first  book  purchased  by  the  medical 
student  is  the  Medical  Dictionary.  The  lexicon 
explanatory  of  technical  terms  is  simply  a  sine  qua 
non.  In  a  science  so  extensive  and  with  such  col- 
laterals as  medicine,  it  is  as  much  a  necessity  also 
to  the  practising  physician.  To  meet  the  wants  of 
students  and  most  physicians  the  dictionary  must 
be  condensed  while  comprehensive,  and  practical 
while  perspicacious.  It  was  because  Dunglison's 
met  these  indications  that  it  became  at  once  the 
dictionary  of  general  use  wherever  medicine  was 
studied  in  the  English  language.  In  no  former 
revision  have  the  alterations  and  additions  been 
so  great.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps; 
an  arrangement  which  greatly  facilitates  reference. 
— Cincinnati  Lancet  and  Clinic,  Jan.  10,  1874. 

A  book  of  which  every  American  ought  to  be 
proud.    When  the  learned  author  of  the  work 


passed  away,  probably  all  of  us  feared  lest  the  book 
should  not  maintain  its  place  in  the  advancing 
science  whose  terms  it  defines.  Fortunately,  Dr. 
Richard  J.  Dunglison,  having  assisted  his  father  in 
the  revision  of  several  editions  of  the  work,  and 
having  been,  therefore,  trained  in  the  methods 
and  imbued  with  the  spirit  of  the  book,  has  been 
able  to  edit  it  as  a  work  of  the  kind  should  be 
edited — to  carry  it  on  steadily,  without  jar  or  inter- 
ruption, along  the  grooves  of  thought  it  has  trav- 
elled during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and 
carried  through,  it  is  only  necessary  to  state  that 
more  than  six  thousand  new  subjects  have  been 
added  in  the  present  edition. — Philadelphia  Medical 
Times,  Jan.  3, 1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references.— London  Medical  Gazette. 


MOBLYN,  MIC II ABU  L>.,  M.  JD. 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 
Sciences.  Eevised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.    Cloth,  $1.50 ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table.— Southern 
Medical  and  Surgical  Journal. 

STUDENTS9  SEBIES  OF  MANUALS. 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine 
and  Surgery,  written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size 
12mo.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price.  The  following  vol- 
umes are  now  ready :  Treves'  Manual  of  Surgery,  by  various  writers,  in  three  volumes, 
each,  $2 ;  Bell's  Comparative  Physiology  and  Anatomy,  $2 ;  Gould's  Surgical  Diagno- 
sis, $2 ;  Kobertson's  Physiological  Physics,  $2 ;  Bruce's  Materia  Medica  and  Therapeu- 
tics, $1.50;  Power's  Human  Physiology,  $1.50;  Clarke  and  Lockwood's  Dissectors' 
Manual,  $1.50;  Kalfe's  Clinical  Chemistry,  $1.50;  Treves'  Surgical  Applied  Anatomy,  $2; 
Pepper's  Surgical  Pathology,  $2 ;  and  Klein's  Elements  of  Histology,  $1.50.  The  following 
are  in  press :  Bellamy's  Operative  Surgery,  Pepper's  Forensic  Medicine,  and  Curnow's 
Medical  Applied  Anatomy.    For  separate  notices  see  index  on  last  page. 

SEBIES  OF  CLINICAL  MANUALS. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the 
profession  with  a  collection  of  authoritative  monographs  on  important  clinical  subjects 
m  a  cheap  and  portable  form.  The  volumes  will  contain  about  550  pages  and  will  be 
freely  illustrated  by  chromo-lithographs  and  woodcuts.  The  following  volumes  are 
now  ready:  Marsh  on  the  Joints,  $2;  Owen  on  Surgical  Diseases  of  Children,  $2; 
Morris  on  Surgical  Diseases  of  the  Kidney,  $2.25 ;  Pick  on  Fractures  and  Dislocations,  $2 ; 
Butlin  on  the  Tongue,  $3.50 ;  Treves  on  Intestinal  Obstruction,  $2 ;  and  Savage  on  Insan- 
ity and  Allied  Neuroses,  $2.  The  following  will  be  ready  shortly:  Hutchinson  on 
Syphilis.  The  following  are  in  active  preparation :  Carter  &  Frost's  Ophthalmic  Surgery, 
Bryant  on  the  Breast,  Broadbent  on  the  Pulse,  Lucas  on  Diseases  of  the  Urethra,  and 
Ball  on  the  Rectum  and  Anus.   For  separate  notices  see  index  on  last  page. 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


5 


GBAY,  HEJSTBY,  F.  B.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  Lond 

Anatomy,  Descriptive  and  Surgical.  The  Drawings  by  H.  V.  Carter,  M.  D., 
and  Dr.  Westxacott.  The  dissections  jointly  by  the  Author  and  Dr.  Carter.  With, 
an  Introduction  on  General  Anatomy  and  Development  by  T.  Holmes,  M.  A.,  Surgeon  to 
St.  George's  Hospital.  Edited  by  T.  Pickering  Pick,  F.  K.  C.  S.,  Surgeon  to  and  Lecturer 
on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Royal  College  of 
Surgeons  of"  England.  A  new  American  from  the  tenth  enlarged  and  improved  London 
edition.  To  which  is  added  the  second  American  from  the  latest  English  edition  of 
Landmarks,  Medicae  astd  Surgicae,  by  Luther  Holden,  F.E.  C.S.,  author  of 
"Human  Osteology,"  "A  Manual  of  Dissections,"  etc.  In  one  imperial  octavo  volume 
of  1023  pages,  with  564  large  and  elaborate  engravings  on  wood.  Cloth,  $6.00 ;  leather, 
$7.00 ;  very  handsome  half  Russia,  raised  bands,  $7.50. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  They  thus  form  a  complete  and 
splendid  series,  which  will  greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy, 
and  will  also  serve  to  refresh  the  memory  of  those  who  may  find  in  the  exigencies  of 

Sractice  the  necessity  of  recalling  the  details  of  the  dissecting-room.  Combining,  as  it 
oes,  a  complete  Atlas  of  Anatomy  with  a  thorough  treatise  on  systematic,  descriptive 
and  applied  Anatomy,  the  work  will  be  found  of  great  service  to  all  physicians  who  receive 
students  in  their  offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the 
groundwork  of  a  thorough  medical  education. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the.  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by 
type  and  illustration  in  anatomical  study. 

This  well-known  work  comes  to  us  as  the  latest  I  There  is  probably  no  work  used  so  universally 
American  from  the  tenth  English  edition.  As  its  by  physicians  and  medical  students  as  this  one. 
title  indicates,  it  has  passed  through  many  hands  !  It  is  deserving  of  the  confidence  that  they  repose 
and  has  received  many  additions  and  revisions.  |  in  it.  If  the  present  edition  is  compared  with  that 
The  work  is  not  susceptible  of  more  improvement,  j  issued  two  years  ago,  one  will  readily  see  how 
Taking  it  all  in  all,  its  size,  manner  of  make-up,  ;  much  it  has  been  improved  in  that  time.  Many 
its  character  and  illustrations,  its  general  accur-  pages  have  been  added  to  the  text,  especially  in 
acy  of  description,  its  practical  aim,  and  its  per-  those  parts  that  treat  of  histology,  and  many  new 
spicuity  of  style,  it  is  the  Anatomy  best  adapted  to  cuts  have  been  introduced  and  old  ones  modified, 
the  wants  of  the  student  and  practitioner. — Medical  — Journal  of  the  American  Medical  Association,  Sept. 
Record,  Sept  15, 1883.   |  1,  1883.  

Also  for  sale  separate— 
HOLDER,  LTJTHEB,  F.  B.  €.  S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals,  London. 

Landmarks,  Medical  and  Surgical.  Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  \Y.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Pennsylvania  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anatomy  in  the  Phila- 
delphia School  of  Anatomy.    In  one  handsome  12mo.  volume  of  148  pages.    Cloth,  $1.00. 

This  little  book  is  all  that  can  be  desired  within  j  cians  and  surgeons  is  much  to  be  encouraged.  It 
its  scope,  and  its  contents  will  be  found  simply  in-  I  inevitably  leads  to  a  progressive  education  of  both 
valuable  to  the  young  surgeon  or  physician,  since  I  the  eye  and  the  touch,  by  which  the  recognition  of 
they  bring  before  him  such  data  as  he  requires  at  disease  or  the  localization  of  injuries  is  vastly  as- 
every  examination  of  a  patient.  It  is  written  in  sisted.  One  thoroughly  familiar  with  the  facts  her« 
language  so  clear  and  concise  that  one  ought  j  taught  is  capable  of  a  degree  of  accuracy  and  a 
almost  to  learn  it  by  heart.  It  teaches  diagnosis  by  confidence  of  certainty  which  is  otherwise  unat- 
external  examination,  ocular  and  palpable,  of  the  tainable.  We  cordially  recommend  the  Landmarks 
body,  with  such  anatomical  and  physiological  facts  to  the  attention  of  every  physician  who  has  not 
as  directly  bear  on  the  subject.  It  is  eminently  yet  provided  himself  with  a  "copy  of  this  useful, 
the  student's  and  young  practitioner's  book. — Phy*  practical  guide  to  the  correct  placing  of  all  the 
sician  and  Surgeon,  Nov.  1881.  anatomical  parts  and  organs. — Canada  Medical  and 

The  study  of  these  Landmarks  by  both  physi-  !  Surgical  Journal,  Dec.  1881. 


WILSON,  ERASMUS,  F.  B.  S. 

A  System  of  Human  Anatomy,  General  and  Special.  Edited  by  W.  H. 
Oobrecht,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustration*. 
Cloth,  $4.00;  leather,  $5.00. 

CLELAND,  JOHN,  M.  !>.,  F.  B.  S., 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Oalvoay, 

A  Directory  for  the  Dissection  of  the  Human  Body.  In  one  12ma 
rolume  of  178  pages.    Cloth,  $1.25. 


6 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


ALLEW,  MABBISON,  M.  IK, 

Professor  oj  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  With  an  Intro- 
ductory Section  on  Histology.  By  E.  O.  Shakespeare,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section  I.  Histology. 
Section  II.  Bones  and  Joints.  Section  III.  Muscles  and  Fasciae.  Section  IV. 
Arteries,  Veins  and  Lymphatics.  Section  V.  Nervous  System.  Section  VI. 
Organs  of  Sense,  of  Digestion  and  Genito-Urinary  Organs,  Embryology, 
Development,  Teratology,  Superficial  Anatomy,  Post-Mortem  Examinations, 
and  General  and  Clinical  Indexes.  Price  per  Section,  $3.50 ;  also  bound  in  one 
volume,  cloth,  $23.00 ;  very  handsome  half  Eussia,  raised  bands  and  open  back,  $25.00. 
For  sale  by  subscription  only.    Apply  to  the  Publishers. 

Extract  from  Introduction. 

It  is  the  design  of  this  book  to  present  the  facts  of  human  anatomy  in  the  manner  best 
suited  to  the  requirements  of  the  student  and  the  practitioner  of  medicine.  The  author 
believes  that  such  a  book  is  needed,  inasmuch  as  no  treatise,  as  far  as  he  knows,  contains,  in 
addition  to  the  text  descriptive  of  the  subject,  a  systematic  presentation  of  such  anatomical 
facts  as  can  be  applied  to  practice. 

A  book  which  will  be  at  once  accurate  in  statement  and  concise  in  terms ;  which  will  be 
an  acceptable  expression  of  the  present  state  of  the  science  of  anatomy ;  which  will  exclude 
nothing  that  can  be  made  applicable  to  the  medical  art,  and  which  will  thus  embrace  all 
of  surgical  importance,  while  omitting  nothing  of  value  to  clinical  medicine, — would  appear 
to  have  an  excuse  for  existence  in  a  country  where  most  surgeons  are  general  practitioners, 
and  where  there  are  few  general  practitioners  who  have  no  interest  in  surgery. 

It  is  to  be  considered  a  study  of  applied  anatomy 
in  its  widest  sense — a  systematic  presentation  of 
such  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgeiy.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  travelled  over  by  one  thoroughly  famil- 
iar with  it.  The  illustrations  are  made  with  great 


care,  and  are  simply  superb.  There  is  as  much 
of  practical  application  of  anatomical  points  to 
the  every-day  wants  of  the  medical  clinician  as 
to  those  of  the  operating  surgeon.  In  fact,  few 
general  practitioners  will  read  the  work  without  a 
feeling  of  surprised  gratification  that  so  many 
points,  concerning  which  they  may  never  have 
thought  before  are  so  well  presented  for  their  con- 
sideration. It  is  a  work  which  is  destined  to  be 
the  best  of  its  kind  in  any  language.— Medical 
Record,  Nov.  25, 1882. 


CLARKE,  W.  B.,  FB.  C.8.  &  LOCKWOOZP, C.  B.,  F.B.  C.S. 

Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical  School,  London. 

The  Dissector's  Manual.  In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49  illustrations.    Limp  cloth,  red  edges,  $1.50.    See  Students'  Series  of  Manuals,  page  4. 


This  is  a  very  excellent  manual  for  the  use  of  the 
student  who  desires  to  learn  anatomy.  The  meth- 
ods of  demonstration  seem  to  us  very  satisfactory. 
There  are  many  woodcuts  which,  for  the  most 


part,  are  good  and  instructive.  The  book  is  neat 
and  convenient.  We  are  glad  to  recommend  it. — 
Boston  Medical  and  Surgical  Journal,  Jan.  17, 1884. 


TMEYES,  FBE1>EBICK,  F.  B.  C.  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 
Surgical  Applied  Anatomy.    In  one  pocket-size  12mo.  volume  of  540  pages, 
with  61  illustrations.  Limp  cloth,  red  edges,  $2.00.    See  Students'  Series  of  Manuals, 
page  4. 


He  has  produced  a  work  which  will  command  a 
larger  circle  of  readers  than  the  class  for  which  it 
was  written.  This  union  of  a  thorough,  practical 
acquaintance  with  these  fundamental  branches, 


quickened  by  daily  use  as  a  teacher  and  practi- 
tioner, has  enabled  our  author  to  prepare  a  work 
which  it  would  be  a  most  difficult  task  to  excel.— 
The  American  Practitioner,  Feb.  1884. 


CUBNOW,  JOMJF,  M.  D.,  F.  B.  C.  P., 

Professor  of  Anatomy  at  King's  College,  Physician  at  King's  College  Hospital. 

Medical  Applied  Anatomy.   In  one  pocket-size  12mo.  volume. 

See  Students'  Series  of  Manuals,  page  4. 


Preparing. 


BELLAMY,  EDWABD,  F.  B.  a  S., 

Senior  Assistant- Surgeon  to  the  Charing-Cross  Hospital,  London. 

The  Student's  Guide  to  Surgical  Anatomy:  Being  a  Description  of  the 
most  Important  Surgical  Kegions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
operative  Surgery.   In  one  12mo.  volume  of  300  pages,  with  50  illustrations.  Cloth,  $2.25. 


HARTSHORNE'S  HANDBOOK  OF  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.   Cloth,  $1.75. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  two  octavo  volumes  of  1007  pages, 
with  320  woodcuts.   Cloth,  $6.00. 


Lea  Brothers  &  Co.'s  Publications — Physics,  Physiol.,  Anat.  7 


DRAPER,  JOHN  C,  M.  I}.,  LL. 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 

Medical  Physics.  A  Text-book  for  Students  and  Practitioners  of  Medicine.  In 
one  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.  Cloth,  $4. 

FROM  THE  PREFACE. 

The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admirable 
works  of  Desplats  and  Gariel,  of  Kobertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  which  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  placing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  many  years  at  the 
University  of  the  City  of  New  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between  Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 


This  elegant  and  useful  work  bears  ample  testi- 
mony to  the  learning  and  good  judgment  of  the 
author.  He  has  fitted  his  work  admirably  to  the 
exigencies  of  the  situation  by  presenting  the 
reader  with  brief,  clear  and  simple  statements  of 
such  propositions  as  he  is  by  necessity  required  to 
master.  The  subject  matter  is  well  arranged, 
liberally  illustrated  and  carefully  indexed.  That 
it  will  take  rank  at  once  among  the  text-books  is 
certain,  and  it  is  to  be  hoped  that  it  will  find  a 
place  upon  the  shelf  of  the  practical  physician, 
where,  as  a  book  of  reference,  it  will  be  found 
useful  and  agreeable—  Louisville  Medical  News, 
September  26, 1885. 

Certainly  we  have  no  text-book  as  full  as  the  ex- 
cellent one  he  has  prepared.  It  begins  with  a 
statement  of  the  properties  of  matter  and  energy. 
After  these  the  special  departments  of  physics  are 


explained,  acoustics,  optics, 
magnetism,  closing  with 


heat,  electricity  and 
section  on  electro- 


biology.  The  applications  of  all  these  to  physiology 
and  medicine  are  kept  constantly  in  view.  The 
text  is  amply  illustrated  and  the  many  difficult 
points  of  the  subject  are  brought  forward  with  re- 
markable clearness  and  ability.— Medical  and  Surg- 
ical Reporter,  July  18, 1885. 

That  this  work  will  greatly  facilitate  the  study 
of  medical  physics  is  apparent  upon  even  a  mere 
cursory  examination.  It  is  marked  by  that  scien- 
tific accuracy  which  always  characterizes  Dr. 
Draper's  writings.  Its  peculiar  value  lies  in  the 
fact  that  it  is  written  from  the  standpoint  of  the 
medical  man.  Hence  much  is  omitted  that  ap- 
pears in  a  mere  treatise  on  physical  science,  while 
much  is  inserted  of  peculiar  value  to  the  physi- 
cian.— Medical  Record,  August  22,  1885. 


ROBERTSON,  J.  McGREGOR,  M.  A.,  M.  B., 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 
Physiological  Physics.    In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.   Limp  cloth,  $2.00.    See  Students1  Series  of  Manuals,  page  4. 


Tne  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
ual for  the  student  of  medicine,  an  auxiliary  to 
his  text-book  in  physiology,  and  it  would  be  particu- 
larly useful  as  a  guide  to  his  laboratory  experi- 


ments. It  will  be  found  of  great  value  to  the 
practitioner.  It  is  a  carefully  prepared  book  of 
reference,  concise  and  accurate,  and  as  such  we 
heartily  recommend  it. — Journal  of  the  American 
Medical  Association,  Dec.  6, 1884. 


DALTON,  JOHN  C,  M.  J>., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York. 

^  Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.    Cloth,  $2. 


Dr.  Dalton's  work  is  the  fruit  of  the  deep  research 
of  a  cultured  mind,  and  to  the  busy  practitioner  it 
cannot  fail  to  be  a  source  of  instruction.  It  will 
inspire  him  with  a  feeling  of  gratitute  and  admir- 
ation for  those  plodding  workers  of  olden  times, 
who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  as  it  now  stands. — New  Orleans 
Medical  and  Surgical  Journal,  Aug.  1885. 

In  the  progress  of  physiological  study  no  fact 
was  of  greater  moment,  none  more  completely 


revolutionized  the  theories  of  teachers,  than  the 
discovery  of  the  circulation  of  the  blood.  This 
explains  the  extraordinary  interest  it  has  to  all 
medical  historians.  The  volume  before  us  is  one 
of  three  or  four  which  have  been  written  within  a 
few  years  by  American  physicians.  It  is  in  several 
respects  the  most  complete.  The  volume,  though 
small  in  size,  is  one  of  the  most  creditable  con- 
tributions from  an  American  pen  to  medical  history 
that  has  appeared. — Med.  dc  Surg.  Rep.,  Dec.  6, 1884. 


BELL,  F.  JEFFREY,  M.  A., 

Professor  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.  In  one  12mo.  volume  of  561  pages, 
with  229  illustrations.  Limp  cloth,  $2.00.    See  Students'  Series  of  Manuals,  page  4. 

The  manual  is  preeminently  a  student's  book- 
clear  and  simple  in  language  and  arrangement. 
It  is  well  and  abundantly  illustrated,  and  is  read- 
able and  interesting.   On  the  whole  we  consider 


it  the  best  work  in  existence  in  the  English 
language  to  place  in  the  hands  of  the  medical 
student. — Bristol  Medico-Chirurgical  Journal,  Mar., 
1886. 


ELLIS,  GEORGE  VINER, 

Emeritus  Professor  of  Anatomy  in  University  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  From  the  eighth  ana  revised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  pages,  with  249  illustrations.  Cloth,  $4.25 ;  leather,  $5.25. 

ROBERTS,  JOHN  B.,  A.  M.,  31.  D., 

Prof,  of  Applied  Anat.  and  Oper.  Surg,  in  Phila.  Polyclinic  and  Coll.  for  Graduates  in  Medicine. 
The  Compend  of  Anatomy.    For  use  in  the  dissecting-room  and  in  preparing 
for  examinations.    In  one  16mo.  volume  of  196  pages.    Limp  cloth,  75  cents. 


8      Lea  Brothers  &  Co.'s  Publications — Physiology,  Chemistry. 


CHAPMAN,  HE  WHY  C,  31.  D., 

Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of 
Philadelphia. 

A  Treatise  on  Human  Physiology.    In  one  handsome  octavo  volume  of 

about  900  pages,  profusely  illustrated.    In  press. 


DALTON,  JOHN  C,  M.  D., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc. 
A  Treatise  on  Human  Physiology.    Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.    Seventh  edition,  thoroughly  revised  and  rewritten.    In  one 
very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00 ;  leather,  $6.00 ;  very  handsome  half  Kussia,  raised  bands,  $6.50. 

This  edition  of  Dr.  Dalton's  well-known  work 
bears  evidence  of  having  been  thoroughly  and 
carefully  revised.   From  the  first  appearance  of 


the  book  it  has  been  a  favorite,  owing  as  well  to 
the  author's  renown  as  an  oral  teacher  as  to  the 
charm  of  simplicity  with  which,  as  a  writer,  he 
always  succeeds  in  investing  even  intricate  sub- 
jects It  must  be  gratifying  to  him  to  observe  the 
frequency  with  which  his  work,written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  fact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  the  thou- 
sands who  have  studied  it  in  its  various  editions 
have  never  been  in  any  doubt  as  to  its  sterling 
worth. — N.  Y.  Medical  Journal  and  Obstetrical  Re- 
view, Oct.  1882. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 


which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — Dublin  Journal  of  Medical  Science,  Feb.'83. 

Certainly  no  physiological  work  as  ever  issued 
from  the  press  that  presented  its  subject-matter  in 
a  clearer  and  more  attractive  light.  Almost  every 
page  bears  evidence  of  the  exhaustive  revision 
that  has  taken  nlace.  The  material  is  placed  in  a 
more  compact  form,  yet  its  delightful  charm  is  re- 
tained, and  no  subject  is  thrown  into  obscurity. 
Altogether  this  edition  is  far  in  advance  of  any 
previous  one,  and  will  tend  to  keep  the  profession 
posted  as  to  the  most  recent  additions  to  our 
physiological  knowledge. — Michigan  Medical  News, 
April,  1882. 


FOSTER,  MICHAEL,  M.  I).,  F.  R.  S., 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.    Third  American  from  the  fourth  English  edition? 
with  notes  and  additions  by  E.  T.  Reichert,  M.  D.,  Professor  of  Physiology  in  the  Uni- 
versity of  Pennsylvania.    In  one  handsome  royal  12mo.  volume  of  908  pages,  with  271 
illustrations.   Cloth,  $3.25 ;  leather,  $3.75. 

Dr.  Foster's  work  upon  physiology  is  so  well- 
known  as  a  text-book  in  this  country,  that  it  needs 
but  little  to  be  said  in  regard  to  it.  There  is 
scarcely  a  medical  college  in  the  United  States 
where  it  is  not  in  the  hands  of  the  students.  The 
author,  more  than  any  other  writer  with  whom 
we  are  acquainted,  seems  to  understand  what 
portions  of  the  science  are  essential  for  students 


to  know  and  what  may  be  passed  over  by  them  as 
not  important.  From  the  beginning  to  the  end, 
physiology  is  taught  in  a  systematic  manner.  To 
this  third  American  edition  numerous  additions, 
corrections  and  alterations  have  been  made,  so 
that  in  its  present  form  the  usefulness  of  the  book 
will  be  found  to  be  much  increased. — Cincinnati 
Medical  News,  July  1885. 


FOWER,  HENRY,  M.  B.,  F.  B.  C.  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.     In  one  handsome  pocket-size  12mo.  volume  of 
with  47  illustrations.    Cloth,  $1.50.    See  Students'  Series  of  Manuals,  page  4. 

to  every  one  of  our  readers. — The  American  Jour- 


The  prominent  character  of  this  work  is  that  of 
judicious  condensation,  in  which  an  able  and  suc- 
cessful effort  appears  to  have  been  made  by  its 
accomplished  author  to  teach  the  greatest  number 
of  facts  in  the  fewest  possible  words.  The  result 
is  a  specimen  of  concentrated  intellectual  pabu- 
%lum  seldom  surpassed,  which  ought  to  be  care- 
fully ingested  and  digested  by  every  practitioner 
who  desires  to  keep  himself  well  informed  upon 
this  most  progressive  of  the  medical  sciences. 
The  volume  is  one  which  we  cordially  recommend 


nal  of  the  Medical  Sciences,  October,  1884. 

This  little  work  is  deserving  of  the  highest 
praise,  and  we  can  hardly  conceive  how  the  main 
facts  of  this  science  could  have  been  more  clearly 
or  concisely  stated.  The  price  of  the  work  is  such 
as  to  place  it  within  the  reach  of  all,  while  the  ex- 
cellence of  its  text  will  certainly  secure  for  it  most 
favorable  commendation — Cincinnati  Lancet  and 
Clinic,  Feb.  16, 1884. 


SIMON,  W.,  Fit.  I).,  M. 


Professor  of  Chemistry  and  Toxicology  in  the  College  of  Physicians  and  Surgeons,  Baltimore,  and 

Professor  of  Chemistry  in  the  Maryland  College  of  Pharmacy. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
In  one  8vo.  vol.  of  410  pp.,  with  16  woodcuts  and  7  plates,  mostly  of  actual  deposits, 
with  colors  illustrating  56  of  the  most  important  chemical  reactions.  Cloth,  $3.00;  also 
without  plates,  cloth,  $2.50. 

This  book  supplies  a  want  long  felt  by  students 
of  medicine  and  pharmacy,  an!  is  a  concise  but 
thorough  treatise  on  the  subject.  The  long  expe- 
rience of  the  author  as  a  teacher  in  schools  of 
medicine  and  pharmacy  is  conspicuous  in  the 
perfect  adaptation  of  the  work  to  the  special  needs 
of  the  student  of  these  branches.    The  colored 


plates,  beautifully  executed,  illustrating  precipi- 
tates of  various  reactions,  form  a  novel  and  valu- 
able feature  of  the  book,  and  cannot  fail  to  be  ap- 
preciated by  both  student  and  teacher  as  a  help 
over  the  hard  places  of  the  science.— Maryland 
Medical  Journal,  Nov.  22  1884. 


Wohler's  Outlines  of  Organic  Chemistry.  Edited  by  Fittig.  Translated 
by  Ira  Kemsen,  M.  D.,  Ph.  D.    In  one  12mo.  volume  of  550  pages.    Cloth,  $3. 

LEHM ANN'S  MANUAL  OF  CHEMICAL  PHYS-  CARPEN  PER'S  PRIZE  ESSAY  ON  THE  USE  AND 

IOLOGY.    In  one  octavo  volume  of  327  pages,  Abuse  of  Alcoholic  Liquors  in  Health  and  Dis- 

with  41  illustrations.   Cloth,  $2.25.  ease.  With  explanations  of  scientific  words.  Small 

CARPENTER'S  HUMAN  PHYSIOLOGY.   Edited  12mo-   178  PaSes-   Cloth'  60  eents- 

by  Henry  Poweb.   In  one  octavo  volume.  GALLOWAY'S  QUALITATIVE  ANALYSIS. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


9 


FRANKJjAND, E., Z>.  C.  L.,  F.R.S.,  &JAFF,  F.  R.9  F. I.  C., 


Professor  of  Chemistry  in  the  Normal  School 
of  Science,  London. 


Assist.  Prof,  of  Chemistry  in  the  Normal 
School  of  Science,  London. 


Inorganic  Chemistry.  In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  plates.    Cloth,  $3.75  ;  leather,  $4.75. 

This  work  should  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certainly  better 
adapted  than  any  work  upon  chemistry,with  which 
we  are  acquainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med- 
icine should  have.  Physicians  who  feel  that  their 
chemical  knowledge  is  behind  the  times,  would 
do  well  to  devote  some  of  their  leisure  time  to  the 
study  of  this  work.  The  descriptions  and  demon- 
strations are  made  so  plain  that  there  is  no  dim- 
culty  in  understanding  them.— Cincinnati  Medical 
News,  January,  1886. 


This  excellent  treatise  will  not  fail  to  take  its 
place  as  one  of  the  very  best  on  the  subject  of 
which  it  treats.  We  have  been  much  pleased 
with  the  comprehensive  and  lucid  manner  in 
which  the  difficulties  of  chemical  notation  and 
nomenclature  have  been  cleared  up  by  the  writers. 
It  shows  on  every  page  that  the  problem  of 
rendering  the  obscurities  of  this  science  easy 
of  comprehension  has  long  and  successfully 
engaged  the  attention  of  the  authors. — Medical 
and  Surgical  Reporter,  October  31, 1885. 


FOWNES,  GEORGE,  Fh.  2>. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em- 
bodying Watts'  Physical  Inorganic  Chemistry.  New  American  edition.  In  one  large 
royal  12mo.  volume  of  1061  pages,  with  168  illustrations  on  wood  and  a  colored  plate. 
Cloth,  $2.75;  leather,  $3.25. 

chemistry  extant.— Cincinnati  Medical  News,  Oc- 
tober, 1885. 

Of  all  the  works  on  chemistry  intended  for  the 
use  of  medical  students,  Fownes'  Chemistry  is 
perhaps  the  most  widely  used.  Its  popularity  is 
based  upon  its  excellence.  This  last  edition  con- 
tains all  of  the  material  found  in  the  previous, 
and  it  is  also  enriched  by  the  addition  of  Watts' 
Physical  and  Inorganic  Chemistry.  All  of  the  mat- 
ter is  brought  to  the  present  standpoint  of  chemi- 
cal knowledge.  We  may  safely  predict  for  this 
work  a  continuance  of  the  fame  and  favor  it  enjoys 
among  medical  students. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1886. 


Fownes1  Chemistry  has  been  a  standard  text- 
book upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  text-book  with  medi- 
cal students.  In  this  work  are  treated  fully :  Heat, 
Light  and  Electricity,  including  Magnetism.  The 
influence  exerted  by  these  forces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical  practitioner.  We  can  commend  the 
work  as  one  of  the  very  best  text-books  upon 


ATTFIELD,  JOHN,  Fh.  IP., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Gfreat  Britain,  etc 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  tenth 
English  edition,  specially  revised  by  the  Author.  In  one  handsome  royal  12mo.  volume 
of  728  pages,  with  87  illustrations.    Cloth,  $2.50 ;  leather,  $3.00. 

to  put  himself  in  the  student's  place  and  to  appre- 
ciate his  state  of  mind. — American  Chemical  Jour- 
nal, April,  1884. 

It  is  a  book  on  which  too  much  praise  cannot  be 
bestowed.   As  a  text-book  for  medical  schools  it 


A  text-book  which  passes  through  ten  editions 
in  sixteen  years  must  have  good  qualities.  This 
remark  is  certainly  applicable  to  Attfield's  Chem- 
istry, a  book  which  is  so  well  known  that  it  is 
hardly  necessary  to  do  more  than  note  the  appear- 
ance of  this  new  and  improved  edition.  It  seems, 
however,  desirable  to  point  out  that  feature  of  the 
book  which,  in  all  probability,  has  made  it  so 
popular.  There  can  be  little  doubt  that  it  is  its 
thoroughly  practical  character,  the  expression 
being  used  in  its  best  sense.  The  author  under- 
stands what  the  student  ought  to  learn,  and  is  able 


is  unsurpassable  in  the  present  state  of  chemical 
science,  and  having  been  prepared  with  a  special 
view  towards  medicine  and  pharmacy,  it  is  alike 
indispensable  to  all  persons  engaged  in  those  de- 
partments of  science.  It  includes  the  whole 
chemistry  of  the  last .Pharmacopoeia.— Pacific  Medi- 
cal and  Surgical  Journal,  Jan.  1884. 


BLOXAM,  CHARLES  L., 

Professor  of  Chemistry  in  King's  College,  London. 

Chemistry,  Inorganic  and  Organic.  New  American  from  the  fifth  Lon- 
don edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.    Cloth,  $3.75 ;  leather,  $4.75. 


Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never  has  occasion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  of 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 
maintains  the  position  it  has  always  held  as  one  of 


the  best  manuals  of  general  chemistry  In  the  Eng- 
lish language. — Detroit  Lancet,  Feb.  1884. 

Professor  Bloxam's  book  is  a  very  satisfactory 
one.  We  know  of  no  treatise  on  chemistry  which 
contains  so  much  practical  information  in  the 
same  number  of  pages.  The  book  can  be  readily 
adapted  not  only  to  the  needs  of  those  who  desire 
a  tolerably  complete  course  of  chemistry,  but  also 
to  the  needs  of  those  who  desire  only  a  general 
knowledge  of  the  subject.  We  take  pleasure  in 
recommending  this  work  both  as  a  satisfactory 
text-book,  ami  ssauseful  book  of  reference. — Los- 
ton  Medical  and  Surgical  Journal,  June  19, 1884. 


REMSEW,  IRA,  M.  !>.,  Fh.  D., 

Professor  of  Chemistry  in  the  Johns  Hopkins  University,  Baltimore. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.  New  (third)  and  revised  edition.  In  one  handsome  royal 
12mo.  volume  of  about  250  pages.  Preparing. 


10 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


C HAULMS,  T.  CMAWSTOUW,  M.  D.,  F.  €.  S.,  M.  S., 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen's  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  with  38  woodcuts  and  1  colored  plate.    Cloth,  $3.50. 

This  is,  we  believe,  the  first  complete  work  of 
the  kind  in  the  English  language,  and  may  well 
serve  to  show  what  progress  is  being  made  in  medi- 
cine. The  student  will  find  condensed  in  one  vol- 
ume such  a  store  of  knowledge  as  would  formerly 
have  cost  him  much  reading  to  gather.  The  book 
will  fully  repay  anyone  to  read,  and  every  library 
should  have  it  for  reference.— New  Orleans  Medical 
and  Surgical  Journal,  April,  1885. 


Dr.  Charles  is  fully  impressed  with  the  import- 
ance and  practical  reach  of  his  subject,  and  he 


has  treated  it  in  a  competent  and  instructive  man- 
ner. We  cannot  recommend  a  better  book  than 
the  present.  In  fact,  it  fills  a  gap  in  medical  text- 
books, and  that  is  a  thing  which  can  rarely  be  said 
nowadays.  Dr.  Charles  has  devoted  much  space 
to  the  elucidation  of  urinary  mysteries.  He  does 
this  with  much  detail,  and  yet  in  a  practical  and 
intelligible  manner.  In  fact  the  author  has  filled 
his  book  with  many  practical  hints.— Medical  Rec- 
ord, December  20,  1884. 


MOFFMAWW,  F.,  A.M.,  Ph.D.,  &  POWER  F.B.,  Fh.D., 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chem.  in  the  Phil.  Coll.  of  Pharmacy. 
A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.  Cloth,  $4.25. 

We  congratulate  the  author  on  the  appearance  tion  of  them  singularly  explicit.  Moreover,  it-  is 
of  the  third  edition  of  this  work,  published  for  the 
first  time  in  this  country  also.  It  is  admirable  and 
the  information  it  undertakes  to  supply  is  both 
extensive  and  trustworthy.  The  selection  of  pro- 
cesses for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  the  descrip- 


exceptionally  free  from  typographical  errors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pharma- 
ceutical Journal  and  Transactions,  1883. 


CLOWFS,  FMAJVK,  D.  Sc.,  London, 

i      Senior  Science- Master  at  the  High  School,  Newcastle-under-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  387  pages,  with  55  illustrations.  Cloth, 
$2.50. 


We  may  simply  repeat  the  favorable  opinion 
which  we  expressed  after  the  examination  of  the 
previous  edition  of  this  work.  It  is  practical  in  its 
aims,  and  accurate  and  concise  in  its  statements. 
— American  Journal  of  Pharmacy,  August,  1885. 

The  style  is  clear,  the  language  terse  and  vigor- 
ous.  Beginning  with  a  list  of  apparatus  necessary 


for  chemical  work,  he  gradually  unfolds  the  sub- 
ject from  its  simpler  to  its  more  complex  divisions. 
It  is  the  most  readable  book  of  the  kind  we  have 
yet  seen,  and  is  without  doubt  a  systematic, 
intelligible  and  fully  equipped  laboratory  guide, 
and  text-book. — Medical  Record,  July  18, 1885. 


MALFF,  CSAMLFS  S.,  M.  JD.,  F.  B.  C.  JP., 

Assistant  Physician  at  the  London  Hospital. 
Clinical  Chemistry.    In  one  pocket-size  12mo.  volume  of  314  pages,  with  1$ 
illustrations.    Limp  cloth,  red  edges,  $1.50. 

This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the  book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ought  to 
know,  of  the  applications  of  chemistry  in  medi- 


See  Students'  Series  of  Manuals,  page  4. 
cine.  Dr.  Ralfe  is  thoroughly  acquainted  with  the 
latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  harmony  with  the 
modern  scientific  methods  and  spirit. — Medical 
Record,  February  2, 1884. 


CLASSF2T,  ALFXAJSfI>FM, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 

Elementary  Quantitative  Analysis.  Translated,  with  notes  and  additions,  by 
Edgar  F.  Smith.  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.    In  one  12mo.  volume  of  324  pages,  with  36  illust.    Cloth,  $2.00. 

and  then  advancing  to  the  analysis  of  minerals  and 
such  products  as  are  met  with  in  applied  chemis- 
It  is  an  indispensable  book  foi 


It  is  probably  the  best  manua1  of  an  elementary 
nature  extant,  insomuch  as  its  methods  are  the 
best.   It  teaches  by  examples,  commencing  with 


pi 

single  determinations,  followed  by  separations 


try.  It  is  an  indispensable  book  for  students  in 
chemistry.— Boston  Journal  of  Chemistry,  Oct.  1878. 


GHFFNE,  WILLIAM  M.,  M.  D., 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 

A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  Based  upon  Bow- 
man's Medical  Chemistry.  In  one  12mo.  volume  of  310  pages,  with  74  illus.  Cloth,  $1.75. 


It  is  a  concise  manual  of  three  hundred  pages, 
giving  an  excellent  summary  of  the  best  methods 
of  analyzing  the  liquids  and  solids  of  the  body,  both 
for  the  estimation  of  their  normal  constituents  and 


the  recognition  of  compounds  due  to  pathological 
conditions.  The  detection  of  poisons  is  treated 
with  sufficient  fulness  for  the  purpose  of  the  stu- 
dent or  practitioner.— Boston  Jl.  of  Chem.  June,'80. 


Lea  Brothers  &  Co.'s  Publications — Pharm.,  Mat.  Med.,  Therap.  11 


BRUNTON,  T.  LAUDER,  M.D.,  D.Sc,  F.R.S.,  F.R.C.F., 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  London,  etc. 

A  Text-book  of  Pharmacology,  Therapeutics  and  Materia  Medica ; 
Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
In  one  handsome  octavo  volume  of  1033  pages,  with  188  illustrations.  Cloth,  $5.50 ; 
leather,  $6.50. 

It  is  a  scientific  treatise  worthy  to  be  ranked  with 
the  highest  productions  in  physiology,  either  in 
our  own  or  any  other  language.  Everything  is 
practical,  the  dry,  hard  facts  of  physiology  being 
pressed  into  service  and  applied  to  the  treatment 
of  the  commonest  complaints.  The  information 
is  so  systematically  arranged  that  it  is  available 
for  immediate  use.  The  index  is  so  carefully 
compiled  that  a  reference  to  any  special  point  is 
at  once  obtainable.  Dr.  Brunton  is  never  satisfied 
with  vague  generalities,  but  gives  clear  and  pre- 
cise directions  for  prescribing  the  various  drugs 
and  preparations.  We  congratulate  students  on 
being  at  last  placed  in  possession  of  a  scientific 
treatise  of  enormous  practical  importance. —  The 
London  Lancet,  June  27,  1885. 

Of  all  the  numerous  publications  of  this  year 


upon  the  subject  of  Pharmacology  the  compre- 
hensive work  of  Brunton  is  clearly  the  most 
important,  and  is  beyond  question  trie  foremost 
English  handbook  of  Materia  Medica  and  Thera- 
peutics since  the  appearance  of  Pereira's  Elements 
of  Materia  Medica  in  1842.  It  is  original  both  in 
the  arrangement  of  the  subjects  and  in  the  mode 
of  treatment,  and  develops  in  a  comprehensive 
manner  the  foundation  principles  of  the  science 
of  Pharmacology  without  leaving  the  needs  of  the 
practitioner  out  of  sight  for  an  instant.  In  fact, 
the  author  has  written  a  book  which  deserves  to 
be  known  far  beyond  the  boundaries  of  England, 
and  can  serve  as  a  model  for  the  pharmacological 
works  of  the  continent  on  account  of  its  happy 
combination  of  theory  with  practice. —  Virchovrs 
Jahresbericht,  Berlin,  1886. 


BARTHOLOW,  ROBERTS,  A.  M.,  M.  D.,  XX.  D., 

Professor  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Medical  College  of  Phila- 
delphia. 

New  Remedies  of  Indigenous  Source:  Their  Physiological  Actions  and 
Therapeutical  Uses.    In  one  octavo  volume  of  about  300  pages.  Preparing. 


PARRISH,  EDWARD, 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 
A  Treatise  on  Pharmacy :  designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.    With  many  Formulae  and  Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand,  Ph.  G.    In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.   Cloth,  $5 ;  leather,  $6. 


No  thorough-going  pharmacist  will  fail  to  possess 
himself  of  so  useful  a  guide  to  practice,  and  no 
physician  who  properly  estimates  the  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most  effective  meth- 
ods of  combination  are  concerned,  can  afford  to 
leave  this  work  out  of  the  list  of  their  works  of 
reference.  The  countiy  practitioner,  who  must 
always  be  in  a  measure  his  own  pharmacist,  will 
find  it  indispensable. — Louisville  Medical  News, 
March  29, 1884. 

This  well-known  work  presents  itself  now  based 
upon  the  recently  revised  new  Pharmacopoeia. 


Each  page  bears  evidence  of  the  care  bestowed 
upon  it,  and  conveys  valuable  information  from 
the  rich  store  of  the  editor's  experience.  In  fact, 
all  that  relates  to  practical  pharmacy — apparatus. 

Srocesses  and  dispensing — has  been  arranged  ana 
escribed  with  clearness  in  its  various  aspects,  so 
as  to  afford  aid  and  advice  alike  to  the  student  and 
to  the  practical  pharmacist.  The  work  is  judi- 
ciously illustrated  with  good  woodcuts — American 
Journal  of  Pharmacy,  January,  1884. 

There  is  nothing  to  equal  Parrish's  Pharmacy 
in  this  or  any  other  language.— London  Pharma- 
ceutical Journal. 


HERMANN,  Dr.  L., 

Professor  of  Physiology  in  the  University  of  Zurich. 

Experimental  Pharmacology.  A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and  with 
extensive  additions,  by  Robert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.  In  one  handsome  12mo.  volume  of  199  pages,  with  32 
illustrations.    Cloth,  $1.50. 

MAISCH,  JOHN  M.,  JPhar.  D., 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  Second  edition.  In  one  handsome  royal  12mo.  volume  of  526  pages, 
with  242  illustrations.    Cloth,  $3.00. 

BRUCE,  J.  MITCHELL,  M.  D.,  F.  R.  C.  P., 

Physician  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Charing  Cro88  Hospital,  London. 

Materia  Medica  and  Therapeutics.  An  Introduction  to  Rational  Treat- 
ment. Fourth  edition.  In  one  pocket-size  12mo.  volume  of  591  pages.  Limp  cloth, 
$1.50.    See  Students'  Series  of  Manuals,  page  4. 

GRIFFITH,  ROBERT  EGLESFIELD,  M.  D. 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  ami  Adminis- 
tering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  additions,  by  John  M.  Maisch, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  pages,  with  38  illustrations.    Cloth,  $4.50 ;  leather,  $5.50. 


12      Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therap. 


STILLE,  A.,  M.I).,  XjL.i).,  &  MAISCH,  J.  M.,  Phar.  D.9 

Professor  Emeritus  of  the  Theory  and  Prac-  Prof,  of  Mat.  Med.  and  Botany  in  Phila. 

tice  of  Medicine  and  of  Clinical  Medicine  College  of  Pharmacy,  Sec'y  to  the  Ameri- 

in  the  University  of  Pennsylvania.  can  Pharmaceutical  Association. 

NEW  ED  IT  I O  N  .—JUST  READY. 

The  National  Dispensatory. 

CONTAINING  THE  NATURAL  HISTORY,  CHEMISTRY,  PHARMACY,  ACTIONS  AND  USES  OF 
MEDICINES,  INCLUDING  THOSE  RECOGNIZED  IN  THE  PHARMACOPOEIAS  OF  THE 
UNITED  STATES,  GREAT  BRITAIN  AND  GERMANY,  WITH  NUMEROUS 
REFERENCES  TO  THE  FRENCH  CODEX. 

Fourth  edition,  revised  to  October,  1886,  and  covering  the  new  British  Pharmacopoeia* 

In  one  magnificent  imperial  octavo  volume  of  1794  pages,  with  311  elaborate 
engravings.  Price  in  cloth,  $7.25  ;  leather,  raised  bands,  $8.00;  very  handsome  half 
Russia,  raised  bands  and  open  back,  $9.00. 

*#*  This  work  will  be  furnished  with  Patent  Ready  Reference  Thumb-letter  Index  for  $1.00 
in  addition  to  the  price  in  any  style  of  binding. 

In  this  new  edition  of  The  National  Dispensatory,  all  important  changes  in  the 
recent  British  Pharmacopoeia  have  been  incorporated  throughout  the  volume,  while  in 
the  Addenda  will  be  found,  grouped  in  a  convenient  section  of  24  pages,  all  therapeutical 
novelties  which  have  been  established  in  professional  favor  since  the  publication  of  the 
third  edition  two  years  ago.  Detailed  information  is  thus  given  of  the  following  among 
the  many  drugs  treated :  Antipyrin,  Cocaine  Hydrochlorate,  Cascara  Sagrada,  Fabiana, 
Franciscea,  various  new  Glycerins,  Gymnocladus,  Hydroquinon,  Hypnone,  Iodol,  Jaca- 
randa,  Lanolin,  Menthol,  Phormium,  Sulphophenol,  Thallin  and  Urethan.  In  this 
edition,  as  always  before,  The  National  Dispensatory  may  be  said  to  be  the  represent- 
ative of  the  most  recent  state  of  American,  English,  German  and  French  Pharmacology, 
Therapeutics  and  Materia  Medica. 


The  National  Dispensatory  is  so  well  and  favor- 
ably known  on  both  sides  of  the  Atlantic  that 
scarcely  anything  else  is  left  to  the  reviewer  than 
to  call  attention  to  the  fact  that  another  edition 
of  this  valuable  work  has  made  its  appearance. 
This  last  edition  surpasses  even  its  predecessors 
in  thoroughness  and  accuracy.  The  fact  that  in 
1884,  when  the  third  edition  was  published,  no 
revision  of  the  British  Pharmacopoeia  had  been 
made  for  seventeen  years,  has  necessitated  a 
thorough  going  over  of  the  whole  work  in  order 
that  references  might  correspond  to  the  last  re- 
vision of  the  work  of  our  British  cousins.  In 
addition  to  these  changes  is  a  fairly  full  rSsume",  in 
the  form  of  addenda,  of  the  more  important  drugs 
which  have  come  into  general  use  in  the  last  two 
or  three  years. —  The  American  Journal  of  the  Med- 
ical Sciences,  April,  1887. 

This,  the  most  comprehensive  of  the  several 
commentaries  on  the  Pharmacopoeias  of  the  United 
States,  Great  Britain  and  Germany  which  has  yet 
appeared,  has  by  this  last  revision  been  brought 


fully  up  to  the  existing  knowledge  upon  the  sub- 
ject treated.  Its  references  to  the  British  Phar- 
macopoeia have  been  amended  for  the  late  and 
much-changed  new  edition  of  that  work;  an  "ad- 
denda" of  twenty-five  pages  has  been  appended, 
treating  of  the  latest  and  most  important  addi- 
tions to  the  materia  medica.  This  work  should 
be  in  the  hands  of  every  physician  and  pharma- 
cist.— Boston  Medical  ana  Surgical  Journal,  Feb.  10, 
1887. 

We  think  it  a  matter  for  congratulation  that  the 
profession  of  medicine  and  that  of  pharmacy  have 
shown  such  appreciation  of  this  great  work  as  to  call 
for  four  editions  within  the  comparatively  brief 
period  of  eight  years.  The  matters  with  which  it 
deals  are  of  so  practical  a  nature  that  neither  the 
physician  nor  the  pharmacist  can  do  without  the 
latest  text- books  on  them,  especially  those  that  are 
so  accurate  and  comprehensive  as  this  one.  The 
book  is  in  every  way  creditable  both  to  the  authors 
and  to  the  publishers. — New  York  Medical  Journal, 
May  21,  1887. 


FABQUHABSOIT,  BOBEBT,  M.  D., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School. 

A  Guide  to  Therapeutics  and  Materia  Medica.  Third  American  edition, 
specially  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia  by 
Frank  Woodbury,  M.  D.   In  one  handsome  12mo.  volume  of  524  pages.   Cloth,  $2.25. 


Dr.  Farquharson's  Therapeutics  is  constructed 
upon  a  plan  which  brings  before  the  reader  all  the 
essential  points  with  reference  to  the  properties  of 
drugs.  It  impresses  these  upon  him  in  such  a  way 
as  to  enable  him  to  take  a  clear  view  of  the  actions 
of  medicines  and  the  disordered  conditions  in 
which  they  must  prove  useful.  The  double-col- 


umned pages — one  side  containing  the  recognized 
physiological  action  of  the  medicine,  and  the  other 
the  disease  in  which  observers  (who  are  nearly  al- 
ways mentioned)  have  obtained  from  it  good  re- 
sults—make a  very  good  arrangement.  The  early 
chapter  containing  rules  for  prescribing  is  excel- 
lent.— Canada  Med.  and  Surg.  Journal,  Dec.  1882. 


EDjES,  bobebt  t.9  m.  jd.9 

Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Department. 

A  Text-Book  of  Materia  Medica  and  Therapeutics.  In  one  octavo  volume 
of  about  600  pages,  with  illustrations.  Preparing. 

STILLE,  ALFRED,  M.  D.^LL.  I)., 

Professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  ofPenna. 

Therapeutics  and  Materia  Medica.  A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  including  their  Description  and  History.  Fourth  edition, 
revised  and  enlarged.  In  two  large  and  handsome  octavo  volumes,  containing  1936  pages. 
Cloth,  $10.00 ;  leather,  $12.00 ;  very  handsome  half  Kussia,  raised  bands,  $13.00. 


Lea  Brothers  &  Co.'s  Publications — Pathol.,  Histol. 


13 


COATS,  JOSEPH,  M.  T>.,  F.  F.  F.  S., 

Pathologist  to  the  Glasgow  Western  Infirmary. 

A  Treatise  on  Pathology.  In  one  very  handsome  octavo  volume  of  829  pages, 
with  339  beautiful  illustrations.    Cloth,  $5.50 ;  leather,  $6.50. 

The  work  before  us  treats  the  subject  of  Path- 
ology more  extensively  than  it  is  usually  treated 
in  similar  works.    Medical  students  as  well  as 


physicians,  who  desire  a  work  for  study  or  refer- 
ence, that  treats  the  subjects  in  the  various  de- 
partments in  a  very  thorough  manner,  but  without 
prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  any  with  which  we  are  acquainted.  It  sets 
forth  the  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,  the  changes  from  a  normal 
condition  effected  in  structures  by  disease,  and 
points  out  the  characteristics  of  various  morbid 
agencies,  so  that  they  can  be  easily  recognized.  But, 
not  limited  to  morbid  anatomy,it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions.  There  is  nothing  belonging  to  its  de- 


partmentof  medicine  that  is  not  as  fully  elucidated 
as  our  present  knowledge  will  admit.— Cincinnati 
Medical  News,  Oct.  1883. 

One  of  the  best  features  of  this  reatise  consists 
in  the  judicious  admixture  of  foreign  observation 
with  private  experience.  Thus  the  subject  is 
presented  in  a  harmonious  manner,  facilitating 
the  study  of  single  topics  and  making  the  entire 
volume  profitable  and  pleasant  reading.  The 
author  includes  in  his  descriptions,  general 
pathology  as  well  as  the  special  pathological  histol- 
ogy of  the  different  systems  and  organs.  He  has 
succeeded  in  offering  to  students  and  practition- 
ers a  thoroughly  acceptable  work.— Medical  Record, 
Dec.  22,  1883. 


gbeew,  t.  henby,  m.  jd., 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Oross  Hospital  Medical  School,  London. 

Pathology  and  Morbid  Anatomy.  Fifth  American  from  the  sixth  revised 
and  enlarged  English  edition.  In  one  very  handsome  octavo  volume  of  482  pages,  with 
150  tine  engravings.    Cloth,  $2.50. 

An  extended  review  of  such  a  well-known  book 
is  unnecessary.  We  had  already  regarded  the 
book  as  a  model  of  its  kind,  and  the  author's  as- 
surance that  he  believes  the  present  edition  to  be 
fully  up  to  date  will  be  received  as  sufficient 
proof  that  nothingof  importance  has  been  omitted. 
The  book  has  been  most  carefully  revised,  and 
bears  upon  every  page  the  marks  of  the  care  and 
accuracy  that  have  won  for  it  an  international 
reputation. — New  York  Medical  and  Surgical  Jour~ 
nal,  July  18,  1885. 


The  fact  that  this  well-known  treatise  has  so 
rapidly  reached  its  sixth  edition  is  a  strong  evi- 
dence of  its  popularity.   The  author  is  to  be  con- 

fratulated  upon  the  thoroughness  with  which  he 
as  prepared  this  work.  It  is  thoroughly  abreast 
with  all  the  most  recent  advances  in  pathology. 
No  work  in  the  English  language  is  so  admirably 
adapted  to  the  wants  of  the  student  and  practi- 
tioner as  this,  and  we  would  recommend  it  most 
earnestly  to  every  one. — Nashville  Journal  of  Medi- 
cine and  Surgery,  Nov.  1884. 


WO ODHEAJD,  G.  SIMS,  M.  JD.,  F.  B.  C.  F.  F., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.    A  Manual  for  Students  and  Practitioners.    In  one  beau- 
tiful octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.    Cloth,  $6.00. 

themselves  with  this  manual.    The  numerous 


It  forms  a  real  guide  for  the  student  and  practi- 
tioner who  is  thoroughly  in  earnest  in  his  en- 
deavor to  see  for  himself  and  do  for  himself.  To 
the  laboratory  student  it  will  be  a  helpful  com- 
panion, and  all  those  who  may  wish  to  familiarize 
themselves  with  modern  methods  of  examining 
morbid  tissues  are  strongly  urged  to  provide 


drawings  are  not  fancied  pictures,  or  merely 
schematic  diagrams,  but  they  represent  faithfully 
the  actual  images  seen  under  the  microscope. 
The  author  merits  all  praise  for  having  produced 
a  valuable  work.— Medical  Record,  May  31, 1884. 


SCHAFFB,  FF>WAFF>  A.,  F.  B.  S., 

Assistant  Professor  of  Physiology  in  University  College,  London. 

The  Essentials  of  Histology.  In  one  octavo  volume  of  246  pages,  with 
281  illustrations.    Cloth,  $2.25. 


This  short  volume  might  be  called  a  companion 
book  to  Green's  Pathology,  and  fills  the  same  place 
In  histology  the  latter  occupies  in  pathology.  This 
book  is  so  short,  clear  and  satisfactory,  as  to  invite 
perusal,  and  repay  any  time  spent  in  doing  so.  We 
think  the  book  deserving  of  the  highest  praise. 
— New  Orleans  Med.  and  Surg.  Journal,  Dec.  1885. 

This  admirable  work  is  a  cheering  example  of 


well-won  success,  earned  by  the  faithful  and  dili- 
gent pursuit  of  excellence  in  presentation  of  this, 
essential  foundation  of  all  true  medical  science. 
Since  this  new  work  of  Professor  Schafer's  wiL 
doubtless  be  speedily  placed  upon  the  list  of  text 
books  required  in  every  medical  college,  we  feel 
that  it  needs  no  further  recommendation  at  our 
hands. — Am.  Jour,  of  the  Med.  Sciences,  Jan.  1886. 


KLEIN,  E„  M.  D.,  F.  B.  S., 

Joint  Lecturer  on  General  Anat.  and  Phys.  in  the  Med.  School  of  St.  Bartholomeio's  Hosp.,  London. 
Elements  of  Histology.  In  one  pocket-size  12mo.  volume  of  360  pages,  with  181 
illus.  Limp  cloth,  red  edges,  $1.50.    See  Students'  Series  of  Manuals,  page  4. 

This  little  volume,  originally  intended  by  its   man  body;  and,  while  small  in  size,  it  is  full  to 
able  author  as  a  manual  for  medical  students, 
contains  much  valuable  information,  systematic- 
ally arranged,  that  will  be  acceptable  to  the 

Seneral  practitioner.  It  gives  a  graphic  and  lucid 
escription  of  every  tissue  and  organ  in  the  hu- 


overflowing  with  important  facts  in  regard  to  these 
multiform  and  complex  structures.  We  know  of 
no  book  of  its  size  that  will  prove  of  greater  value 
to  medical  students  and  practitioners  of  medi- 
cine.— The  Southern  Practitioner,  Nov.  1883. 


FEFFFB,  A.  J.,  M.  B.,  M.  S.,  F.  B.  C.  S., 

Surgeon  and  Lecturer  at  St.  Mary's  Hospital,  London. 
Surgical  Pathology.    In  one  pocket-size  12mo.  volume  of  511  pages,  with  81 
illustrations.  Limp  cloth,  red  edges,  $2.00.    See  Students'  Series  of  3fanuals,  page  4, 


It  is  not  pretentious,  but  it  will  serve  exceed- 
ingly well  as  a  book  of  reference.   It  embodies  a 

Sreat  deal  of  matter,  extending  over  the  whole 
eld  of  surgical  pathology.  Its  form  is  practical, 
its  language  is  clear,  and  the  information  set 
forth  is  well-arranged,  well-indexed  and  well- 


illustrated.  The  student  will  find  in  it  nothing 
that  is  unnecessary.  The  list  of  subjects  covers 
the  whole  range  of  surgery.  The  book  supplies  a 
very  manifest  want  and  should  meet  with  suo- 
cess.— New  York  Medical  Journal,  May  31,  1884. 


Cornil  and  Ranvier's  Pathological  Histology.  —  Translated  by  E.  O. 
Shakespeare,  M.  D.,  and  J.  Henry  C.  Simes,  M.  D.  Octavo,  800  pp.,  360  illustrations. 


14 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


FLINT/ AUSTIN,  M.  D., 

Prof,  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med.  in  Bellevue  Hospital  Medical  College,  N.  7. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 

the  use  of  Students  and  Practitioners  of  Medicine.  New  (sixth)  edition,  thoroughly  re- 
vised and  rewritten  by  the  Author,  assisted  by  William  H.  Welch,  M.  D.,  Professor  of 
Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Flint,  Jr.,  M.  D.,  LL.  D., 
Professor  of  Physiology,  Bellevue  Hospital  Medical  College,  N.  Y.  In  one  very  handsome 
octavo  volume  of  about  1170  pages,  with  illustrations.  Cloth,  $5.50;  leather,  $6.50; 
very  handsome  half  Russia,  raised  bands,  $7.00. 

general  approval  by  medical  students  and  practi- 
tioners as  the  work  of  Professor  Flint.  In  all  the 
medical  colleges  of  the  United  States  it  is  the  fa- 
vorite work  upon  Practice;  and,  as  we  have  stated 
before  in  alluding  to  it,  there  is  no  other  medical 
work  that  can  be  so  generally  found  in  the  libra- 
ries of  physicians.  In  every  state  and  territory 
of  this.vastcountry  the  book  that  will  be  most  likely 
to  be  found  in  the  office  of  a  medical  man,  whether 
in  city,  town,  village,  or  at  some  cross-roads,  is 
Flint's  Practice.  We  make  this  statement  to  a 
considerable  extent  from  personal  observation,  and 
it  is  the  testimony  also  of  others.  An  examina- 
tion shows  that  very  considerable  changes  have 
been  made  in  the  sixth  edition.  The  work  may  un- 
doubtedly be  regarded  as  fairly  representing  the 
present  state  of  the  science  of  medicine,  and  as 
reflecting  the  views  of  those  who  exemplify  in 
their  practice  the  present  stage  of  progress  of  med- 
ical art. — Cincinnati  Medical  News,  Oct.  1886. 


A  new  edition  of  a  work  of  such  established  rep- 
utation as  Flint's  Medicine  needs  but  few  words  to 
commend  it  to  notice.  It  may  in  truth  be  said  to 
embody  the  fruit  of  his  labors  in  clinical  medicine, 
ripened  by  the  experience  of  a  long  life  devoted  to 
its  pursuit.  America  may  well  be  proud  of  having 
produced  a  man  whose  indefatigable  industry  and 
gifts  of  genius  have  done  so  much  to  advance  med- 
icine; and  all  English-reading  students  mu^t  be 
grateful  for  the  work  which  he  has  left  behind  him. 
It  has  few  equals,  either  in  point  of  literary  excel- 
lence, or  of  scientific  learning,  and  no  one  can  fail 
to  study  its  pages  without  being  struck  by  the  lu- 
cidity and  accuracy  which  characterize  them.  It 
is  qualities  such  as  these  which  render  it  so  valu- 
able for  its  purpose,  and  give  it  a  foremost  place 
among  the  text-books  of  this  generation. —  The 
London  Lancet,  March  12, 1887. 

No  text-book  on  the  principles  and  practice  of 
medicine  has  ever  met  in  this  country  with  such 


HARTSHORNE,  HENRY,  M.  JO.,  LL.  !>., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 

for  Students  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.    Cloth,  $2.75 ;  half  bound,  $3.00. 


Within  the  compass  of  600  pages  it  treats  of  the 
history  of  medicine,  general  pathology,  general 
symptomatology,  and  physical  diagnosis  (including 
laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  it  is  one  of  the  best 
of  its  kind  that  we  have  seen. — Glasgow  Medical 
Journal,  Nov.  1882. 

An  indispensable  book.  No  work  ever  exhibited 
&  better  average  of  actual  practical  treatment  than 


this  one;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials, as  the  name  suggests,  are  not  intended  to 
supersede  the  text-books  of  Flint  and  Bartholow, 
but  they  are  the  most  valuable  in  affording  the 
means  to  see  at  a  glance  the  whole  literature  of  any 
disease,  and  the  most  valuable  treatment. — Chicago 
Medical  Journal  and  Examiner,  April,  1882. 


B  BIS  TO  WE,  JOHN  SYER,  M.  JO.,  F.  R.  C.  P., 

Physician  and  Joint  Lecturer  on  Medicine  at  St.  Thomas'  Hospital,  London. 

A  Treatise  on  the  Practice  of  Medicine.  Second  American  edition,  revised 
by  the  Author.  Edited,  with  additions,  by  James  H.  Hutchinson,  M.D.,  physician  to  the 
Pennsylvania  Hospital.  In  one  handsome  octavo  volume  of  1085  pages,  with  illustrations. 
Cloth,  $5.00;  leather,  $6.00;  very  handsome  half  Russia,  raised  bands,  $6.50. 


The  book  is  a  model  of  conciseness,  and  com- 
bines, as  successfully  as  one  could  conceive  it  to 
be  possible,  an  encyclopaedic  character  with  the 
smallest  dimensions.  It  differs  from  other  admi- 
rable text-books  in  the  completeness  with  which 
it  covers  the  whole  field  of  medicine. — Michigan 
Medical  News,  May  10,  1880. 

His  accuracy  in  the  portraiture  of  disease,  his 
care  in  stating  subtle  points  of  diagnosis,  and  the 
faithfully  given  pathology  of  abnormal  processes 
have  seldom  been  surpassed.  He  embraces  many 
diseases  not  usually  considered  to  belong  to  theory 


and  practice,  as  skin  diseases,  syphilis  and  insan- 
ity, but  they  will  not  be  objected  to  by  readers,  as 
he  has  studied  them  conscientiously,  and  drawn 
from  the  life. — Medical  and  Surgical  Reporter,  De- 
cember 20, 1879. 

The  reader  will  find  every  conceivable  subject 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  style  at  once  clear,  interesting  and 
concise.  The  additions  made  by  Dr.  Hutchinson 
are  appropriate  and  practical,  and  greatly  add  to 
its  usefulness  to  American  readers. — Buffalo  Med- 
ical and  Surgical  Journal,  March,  1880. 


WATSON,  SIR  THOMAS,  M.  I)., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 

from  the  fifth  English  edition.  Edited,  with  additions,  and  190  illustrations,  by  Henry 
Hartshorne,  A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
In  two  large  octavo  volumes  ot  1840  pages.    Cloth,  $9.00 ;  leather,  $11.00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  Hudson,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
v  olume  of  308  pages.   Cloth,  $2.50. 

STOKES'  LECTURES  ON  FEVER.  Edited  by 
John  William  Moore,  M.  D.,  F.  K.  Q.  C.  P.  In 
one  octavo  volume  of  280  pages.   Cloth,  $2.00. 


A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.   Inone8vo.  vol.  of  354  pp.  Cloth,  $2.25. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.   Cloth,  $7.00. 


A  CENTURY  OF  AMERICAN  MEDICINE,  1776—1876.  By  Drs.  E.  H.  Clabke,  H.  J. 
Biqklow,  8.  D.  Gbos8,  T.  G.  Thomas,  and  J.  S.  Billings.  In  one  12mo.  volume  of  370  pages.  Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications— S^t^nrr^St^ttl 


16 


For  Sale  by  Subscription  <^Z^vl\O£l^TLT0r5. 


H 

ao 


A  System  of  Practical 

BY  AMERICAN  A  J/WQMl 


Edited  by  WILLIAM  PEPPER^p<©j.  ?tt aidT 

.ft  mo  lo  slsnoitei  9rfi  nMcjx9  oJ  i9job 
PROVOST  AND  PROFESSOR  OF  THE  THEORY  A^n^^^^fi^^^^mf^b3^'11^- 
CLINICAL  MEDICINE  IN  THE  UNIVEI^«G¥W  KEN«S^2^V9ft^Apoi);)fi  9^  *Z9£I 

ab  81  Si    .badssanh  gr  snoiJqhoasiq  9l9i9 
Assisted  by  Louis  Starr,  M.  D.,  Clinical  Professor*©*-  th©  Edse^aesdofii^hikteiifilfi^  tl& 


The  complete  work, 
Price  per  volume, 

.show  9ili  oi  9jjIbv  bb&  Iliw  b9qod 
In  this  great  work  American  medicine  is  for  tke  fic&  time  reflected  by  its  worthiest 
teachers,  and  presented  in  the  full  develojSn^fforTne  practical  utility  which  is  ita,. pre- 
eminent characteristic.    The  most  able*  Wfl^Mrm1 1§ftP  East  •aMItke^ty%s§JrrWft  the 
North  and  the  South,  from  all  the  prominent  centres  of  education*  and_  fr 


hospitals  which  afford  special  opportullJfce^\SfiL^&^ln3»  pallet^ 
generous  rivalry  to  bring  together  tMsf<v§i^;a^p^^<fc©£^ 

The  distinguished  editor  has  so  f$$Q$i$$e$j\lff  wpsfej$>$&$^%^  M^S^feasftbeen 
assigned  the  subject  which  he  is  p^cjqlia^ljy^^p^^^fe^oi^ti?  §tM?)S[t^  ,^fcwA 
will  be  accepted  as  the  latest  expression;,  of  ^-scientific  , and  .practical  knowledge*  jiTlia 
practitioner  will  therefore  find  these,  volume?  a  complete.,  authoritative.! .ftp*!] pfeHiug  work 
of  reference,  to  which  he  may  at  all  times,:turn  with  full  certainty  p£  finding  jwhat  'lie  ueeda£ 
in  its  most  recent  aspect,  whether^eLs.e^kS-MfQrmation  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  trea^tpient-  of  special-disease.^  So  wide  is  the  scope  of  th© 
work  that,  with  the  exception  of  midwifery -and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including-  the  departments  for-  Which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  .as. diseases  of  women  .and'  children,  of  the  genit&u^tnary 
organs,  of  the  skin,  of  the  nerviffi,fhr^^i^aa4  sMiiaryusaieffc^^^fid  Medical  ophthalmel^gy3 
and  otology.  Moreover,  author^liav-e-inserted^-the  formulas  which  they  have  found  most 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount,  of  practical  information  fur- 
nished, it  has  been  impossible,  tc i  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5600  beautifully  printed  pages,  and  embodying  the  matter  of  about.  15  ordinary 
octavos.   Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

A  detailed  prospectus  of  the  work  will  be  sent  to  amy  address  on  application  to  the 

publishers.  .aane^qeiim^fliamBnoi 
These  two  volumes  bring  this  admirable, work 
to  a  close,  and  fully  sustain  the  high  standard 


reached  by  the  earlier  volumes;,  .-we-hare  -only 
therefore  to  echo  the  eulogium-pronouneed  upon 
them.  We  would  warmly  congratulate  the  editor 
and  his  collaborators  at  the  conclusion  of  their 
laborious  task  on  the,  admirable  manner  in  which, 
from  first  to  -last,  they  have  performed  their  several 
duties.  They  have  succeeded  in  producing  a 
work  which  will, long  remain  a  standard  work  of 
reference,  to  which  practitioners  will  look  for 
guidance,  and  authors  will  resort  to  for  factsv- 
From  a  literary  point  of  view,  the  work  is  without 
any  serious  blemish,  and  in  respect  of  production", 
it  has  the  beautiful  finish  that  Americans  always 
give  their  works.— Edinburgh  Medical  Journal,  Jan. 
1887.  I  ^una  .BiHuugmu 

*  *  The  greatesi  distitiCtitely  American  work  on 
the  practice  of  medicine,  and,  indeed,  the  super- 
lative adjective  would  not  be  inappropriate  were 
even  all  other  productions  placed  in  comparison. 
An  examination  of  the  five  volumes  is  sufficient 
to  convince  one  of  the  magnitude  of  the  enter- 
prise, and  of  the  success  which  has  attended  its 
fulfilment.—?1/^  Medical  Age,  July  26,  1886. 

Convenience  and  good  order,  with,  easy  refer- 
ence, are  no  less  characteristic  than  the  almost 
unfforfmo  excellence  of  the'  matter.-^-iVeu?  York 
Medical  Journal,  June  19, 1886. 

We  consider  it  one  of  the  grandest  works  on 
Practical  Medicine  in  the  English,  language.  It  is 
a  work  of  which  the  profession  of  this  country  can 
f^kaK§H^AI?JM^^Blft9A5K^lJI  fey  American 

{tnxsleians  wB%are  aoduaiated  with  all  the  tarie- 
i<fek)f-44im*M  In  W^iffied^te^^^'^ar^ctHr, 
of  the  soil,  the  manate^tntfftolitbms  <6t  the'peo- 


eirf*  lo  noiiibe  bnoosa  a  eea  oi  beeselq  oia  e77 
pie,  etc.,  it  is  peculiarly  adapted  to  the  wants 
of  American  practitioners  of  medicine,  and  it 
peBmb  to. us  that  every  one  of  them  would  desire 
to  have  it.  It  has  been  truly  called  a  "Complete 
Library  of  Practical  Medicine,"  and  the  general 
practitioner  will  require  little  else  in  his  round 
of  professional  duties. — Cincinnati  Medical  News, 


Marefy  1886. 


Each  of  the  volumes  is  provided  with  a  most 
copious  index,  and  the  work  altogether  promises 
to  (be  ©nevrhioh.  will  add  mueh  to  the  medical 
literature  of  the  present  century,  and  reflect  great 
credit  upon  the  scholarship  and  practical  acumen 
of  its  authors.—  The  London  Lancet,  Oct.  3,  1885. 

The  feeling  of  proud  satisfaction  with  which  the 
American  profession^  sees  this,  its  representative 
system  of  practical, medicine  issued  to  the  medi- 
cal world,  is  fully  justified  by  the  character  of  the 
work.  The  Bntlre  caste  of  the  system  is  in  keep- 
ing with  the  best  thoughts  of  the"  leaders  and  fol- 
lowers of  our  home  school  of  medicine,  and  the 
combination  of  the  scientific  study  of  disease  and 
the  practical  application  of  exact  and  experimen- 
tal knowledge  to  the  treatment  of  human  mal- 
adies, makes  everv  one  of  us  share  in  the  ptide 
that  has  welcomed  Dr.  Pepper's  labors.  Sheared 
of  the  prolixity  that  wearies  the  readers  of  the 
German  school,  the  articles  glean  these  same 
fields  for  all  that  is  valuable.  It  is  the  outcome 
of  American  brains,  and  is  marked  throughout 
by  much  of  the  sturdv  independence  of  thought 
and  originality  fhat  is  a  national  characteristic. 
Yet  nowhere  is  there  lack  of  study  of  the  most 
advanced  views  of  the  day.— North  Carolina  Afedi- 

SI^HSHTOlRflioIoy  .omSI  Hem*  BOO  nl 


16        Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 


FO THE B GILL,  J.  M.,  M.  D.,  Edin,.  M.  B.  C.  P.,  Land., 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics. New  (third)  edition.  In  one  octavo  volume  of  661  pages.  Cloth,  $3.75 ;  leather, 

$4.75.  Just  ready.  „ .  „MC< 

*  FROM  THE  AUTHOR'S  PREFACES. 

This  work  is  not  an  imperfect  Practice  of  Physic,  but  an  attempt  of  an  original  char- 
acter to  explain  the  rationale  of  our  therapeutic  measures.  First  the  physiology  of  each 
subject  is  given  and  then  the  pathology  is  reviewed,  so  far  as  they  bear  upon  the  treatment ; 
next  the  action  of  remedies  is  examined ;  after  which  their  practical  application  in  con- 
crete prescriptions  is  furnished.  It  is  designed  to  supply  to  the  practitioner  reasons  for 
the  faith  that  is  in  him ;  and  is  a  work  on  medical  tactics  for  the  bedside,  rather  than  for 
the  examination  table.  It  has  been  carefully  revised,  and  considerable  additions 
have  been  made  to  it.  A  chapter  on  "  The  Dietary  in  Acute  Disease  and  Malassimila- 
tion  "  indicates  the  growing  importance  of  dietetics  in  the  treatment  of  disease,  and  a 
second  new  chapter  has  been  added  on  the  "  Management  of  Convalescence,"  which  it  is 
hoped  will  add  value  to  the  work. 

By  the  same  Author. 
Mind  and  Liver.   In  one  12mo.  volume  of  about  125  pages.   In  press. 


REYNOLDS,  J.  BUSSELL,  M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 
A  System  of  Medicine.  With  notes  and  additions  by  Henry  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  double-columned  pages,  with  317  illustra- 
tions. Price  per  volume,  cloth,  $5.00 ;  sheep,  $6.00 ;  very  handsome  half  Russia,  raised  bands, 
$6.50.    Per  set,  cloth,  $15 ;  leather,  $18 ;  half  Eussia,  $19.50.    Sold  only  by  subscription. 

STILLE,  ALFRED,  M.  D.,LL.D., 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 
Cholera:  Its  Origin,  History,  Causation,  Symptoms,  Lesions,  Prevention  and  Treat- 
ment. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart.  Cloth,  $1.25.  Just  ready. 


FINLATSON,  JAMES,  31.  D.,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

Clinical  Manual  for  the  Study  of  Medical  Cases.  With  Chapters 
by  Prof.  Gairdner  on  the  Physiognomy  of  Disease;  Prof.  Stephenson  on  Diseases  of 
the  Female  Organs;  Dr.  Eobertson  on  Insanity;  Dr.  Gemmell  on  Physical  Diagnosis ; 
Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor  on  Case- 
taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  New  edition. 
In  one  12mo.  volume  of  682  pages,  with  158  illustrations.   Cloth,  $2.50.   Just  ready. 


We  are  pleased  to  see  a  second  edition  of  this 
admirable  book,  which  occupies  a  position  in 
medical  literature  that  previous  to  the  first  ap- 
pearance of  this  work  was  unoccupied.  It  is 
essentially  a  practical  treatise  on  medical  diagno- 
sis, in  which  every  sign  and  symptom  of  disease 
is  carefully  analyzed,  and  their  relative  signifi- 
cance in  the  different  affections  in  which  they 
occur  pointed  out.  From  their  synthesis  the  stu- 
dent can  accurately  determine  the  disease  with 
which  he  has  to  deal.  The  book  has  no  competi- 
tor, nor  is  it  likely  to  have  as  long  as  future  edi- 


tions maintain  its  present  standard  of  excellence. 
It  is  a  book  which  will  greatly  aid  the  work  of 
the  clinical  teacher,  and  should  be  thoroughly 
digested  by  every  student  of  medicine.  The 
general  practitioner  will  find  many  practical  hints 
in  its  pages,  while  a  careful  study  of  the  work 
will  save  him  from  many  pitfalls  in  diagnosis. 
The  book,  therefore,  in  our  opinion,  commends 
itself  to  a  wide  field  of  readers,  and  we  sincerely 
wish  it  the  great  success  which  it  so  richly  merits. 
— Liverpool  Medico- Chirurgical  Journal,  Jan.  1887. 


FENWICK,  SAMUEL,  M.  D., 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  English  edition.    In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 

87  illustrations  on  wood.    Cloth,  $2.25. 

MABEBSHOJF,  S.  O.,  M.  D.,  ~~ 

Senior  Physician  to  and  late  Led.  on  Principles  and  Practice  of  Med.  at  Guy's  Hospital,  London. 

On  the  Diseases  of  the  Abdomen ;  Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.  In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.    Cloth,  $3.50. 

TAKNEB,  THOMAS  JBLA  WILES,  M.  D. 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 

from  the  second  London  edition.  Kevised  and  enlarged  by  Tilbury  Fox,  M.  D. 
In  one  small  12mo.  volume  of  362  pages,  with  illustrations.    Cloth,  $1.50. 


Lea  Brothers  &  Co.'s  Publications — Hygiene,  Electr.,  Pract.  17 


BARTHOLOW,  ROBERTS,  A.  M.,  M.  D.,  LL.  D., 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Phila.,  etc. 

Medical  Electricity.  A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.  New  (third)  edition.  In  one  very  handsome  octavo  volume  of 
308  pages,  with  110  illustrations.    Cloth,  §2.50.    Just  ready. 

FROM  THE  PREFACE  TO  THE  THIRD  EDITION. 

It  would  be  a  mere  affectation  of  indifference,  which  I  am  far  from  feeling,  to  refrain 
from  the  expression  of  my  gratification  that  the  publishers  of  this  work  have  called  on 
me  to  prepare  a  new  edition,  and  my  gratification  is  the  greater  in  that  the  sale  of  this 
and  other  works  on  Medical  Electricity  afford  indubitable  evidence  of  growth  in  the 
appreciation  of  electricity  as  a  remedial  agent  by  the  medical  profession  in  general. 
That  this  force  should  be  utilized  in  therapeutics,  just  as  any  drug  is  employed  as  a 
remedy,  is  a  fact  of  the  highest  importance.  As  stated  in  the  preface  to  the  first  edition, 
one  of  my  purposes  in  preparing  the  work  was  to  afford  some  aid  in  generalizing  medical 
electricity.  The  new  material  which  appears  in  this  edition  is  chiefly  practical  in  char- 
acter, the  most  important  additions  having  been  made  to  the  therapeutical  sections. 

RICHARDSON,  B.  W.,  31. A.,  31. D.,  LL.  D.,  F.R.S.,  F.S.A. 

FeUow  of  the  Royal  College  of  Physicians,  London. 

Preventive  Medicine.  In  one  octavo  volume  of  729  pages.  Cloth,  $4;  leather, 
$5 ;  very  handsome  half  Russia,  raised  bands,  $5.50. 


Dr.  Richardson  has  succeeded  in  producing  a 
work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  character,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.  He  evinces  the  happy 
faculty  of  extracting  the  pith  of  what  is  known  on 
the  subject,  and  of  presenting  it  in  a  most  simple, 
intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  the  general  public 
that  contains  such  a  complete,  reliable  and  instruc- 


tive collection  of  data  upon  the  diseases  common 
to  the  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly;  the  discussion  of 
the  question  of  disease  is  comprehensive,  masterly 
and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable. —  The 
American  Journal  of  the  Medical  Sciences,  April,  1884. 


HARTSHORNE,  HENRY,  31.  D.,  LL.  D., 

Formerly  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  and  Professor  of  Physiology  and 
Diseases  of  Children  in  the  Woman's  Medical  College  of  Pennsylvania. 

A  Household  Manual  of  Medicine,  Surgery,  Nursing  and  Hygiene: 
For  Daily  Use  in  the  Preservation  of  Health  and  Care  of  the  Sick  and  Injured,  with  an 
Introductory  Outline  of  Anatomy  and  Physiology.  In  one  very  handsome  royal  octavo 
volume  of  946  pages,  with  8  plates  and  283  engravings.  Cloth,  $4.00 ;  very  handsome 
half  Morocco,  $5.00.  

THE  YEAR-BOOK  OF  TREATMENT  FOR  1886. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine.   In  one  12mo.  volume  of  309  pages,  bound  in  limp  cloth,  $1.25. 

every  practitioner,  whether  he  be  a  general  one  or 
a  specialist.  It  is  a  book  to  be  kept  on  the  office 
table  for  continuous  reference.  An  excellent  in- 
dex to  subjects,  as  well  as  to  authors  quoted,  is 
appended. —  Virginia  Medical  Monthly,  April,  1887. 


This  "review"  includes  every  department  of 
medical  and  surgical  as  well  as  obstetrical  practice. 
It  attempts  nothing  in  the  way  of  etiology,  diag- 
nosis or  symptoms,  but  limits  itself  to  the  ad- 
vances made  in  the  treatment  of  diseases,  injuries, 
etc.   The  work  seems  to  us  to  be  invaluable  to 


For  special  commutations  with  periodicals  see  page  3. 


THE  YEAR-BOOK  OF  TREATMENT  FOR  1885. 

Similar  to  that  of  1886  above.    12mo.,  320  pages.    Limp  cloth,  $1.25. 

SCHREIBER,  DR.  JOSEPH. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Walter  Mendelson,  M.  D.,  of  New  York.  In  one  handsome 
octavo  volume  of  278  pages,  with  117  fine  engravings.    Just  ready.    Cloth,  $2,75. 

BROADBENT,  W.  H.,  M.  D.,  F.  R.  C.  P., 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary's  Hospital.  » 
The  Pulse.  In  one  12mo.  volume.  Preparing.  See  /Series  of  Clinical  3Ianuals,  page  4. 


STURGES'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
12mo.  volume  of  127  pages.   Cloth,  81.25. 

DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  S.  Davis, 
M.  D.  Edited  by  Fbank  H.  Davis,  M.  D.  Second 
edition.   12mo.  287  pages.   Cloth,  $1.75. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
820  pages.   Cloth,  $2.50. 


PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.   Cloth,  $2.00. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Condi*, 
M.  D.   1  vol.  8vo.,  pp.  603.    Cloth,  $2.50. 

CHAMBERS' MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.   Cloth,  $2.75. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8vo.,  pp.  493.   Cloth,  $3.50. 


18 


Lea  Brothers  &  Co.'s  Publications — Throat,  Lungs,  Heart. 


FLINT,  AUSTIN,  M.  JD., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  BeUevue  Hospital  Medical  College,  N.  7. 

A.  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 

Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fourth  edition.  In  one 
handsome  royal  12mo.  volume  of  278  pages,  with  14  illustrations.  Cloth,  $1.75. 


The  student  needs  a  first-class  text-book  in 
which  the  subject  is  fully  explained  for  him  to 
study.  Dr.  Flint's  work  is  just  such  a  book.  It 
contains  the  substance  of  the  lessons  which  the 
author  has  for  many  years  given  in  connection 
with  practical  instruction  in  auscultation  and 


percussion  to  private  classes,  composed  of  medical 
students  and  practitioners.  The  fact  that  within 
a  little  more  than  two  years  a  large  edition  of  this 
manual  has  been  exhausted,  is  proof  of  the  favor 
with  which  it  has  been  regarded  by  the  medical 
profession. — Cincinnati  Medical  News,  Feb.  1886. 


BY  THE  SAME  AUTHOR. 

Physical  Exploration  of  the  Lungs  by  Means  of  Auscultation  and 
Percussion.  Three  lectures  delivered  before  the  Philadelphia  County  Medical  Society, 
1882-83.    In  one  handsome  small  12mo.  volume  of  83  pages.    Cloth,  $1.00. 

A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.    In  one  handsome  octavo  volume  of  591  pages.    Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis; In  a  series  of  Clinical  Studies.  In  one  handsome  octavo  volume  of  442  pages. 
Cloth,  $3.50.   

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 
Diseases  of  the  Heart.  Second  revised  and  enlarged  edition.  In  one  octavo  volume 
of  550  pages,  with  a  plate.    Cloth,  $4. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.    Cloth,.  $1.38. 


BROWNE,  LENNOX,  F.  R.  C.  S.,  Edin., 

Senior  Surgeon  to  the  Central  London  Throat  and  Ear  Hospital,  etc. 
The  Throat  and  its  Diseases.    Second  American  from  the  second  English  edi- 
tion, thoroughly  revised.    With  200  engravings  and  120  illustrations  in  colors.    In  one 
very  handsome  imperial  octavo  volume  of  about  350  pages.  Shortly. 

GROSS,  S.  L>.,  M.D.,  LL.l).,  JD.C.L.  Oxon.,  LL.D.  Cantab. 
A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.  In  one 

octavo  volume  of  452  pages,  with  59  illustrations.    Cloth,  $2.75. 


COHEN,  J.  SOLIS,  M.  &., 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  (Esophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.  Preparing. 


SELLER,  CARL,  M.  D., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.    Second  edition.    In  one  handsome  royal  12mo.  volume 

of  294  pages,  with  77  illustrations.    Cloth,  $1.75. 


It  is  one  of  the  best  of  the  practical  text-books 
on  this  subject  with  which  we  are  acquainted.  The 
present  edition  has  been  increased  in  size,  but  its 
eminently  practical  character  has  been  main- 
tained. Many  new  illustrations  have  also  been 
introduced,  a  case-record  sheet  has  been  added, 


and  there  are  8  valuable  bibliography  and  a  good 
index  of  the  whole.  For  any  one  who  wishes  to 
make  himself  familiar  with  the  practical  manage- 
ment of  cases  of  throat  and  nose  disease,  the  book 
will  be  found  of  great  value. — New  York  Medical 
Journal,  June  9, 1883. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND 
AIR-PASS  AGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.   Cloth,  $3.50. 

BLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.   In  one  12mo.  vol.,  rip.  158.   Cloth,  $1.25. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.  In  1  vol.  8vo.,  416  pp.   Cloth,  $3.00. 


SMITH  ON  CONSUMPTION;  its  Early  and  Reme- 
diable Stages.   1  vol.  8vo.,  pp.  253.   Cloth,  $2.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.   Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration-  In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.50. 

JONES'  CLINICAL  OBSERVATIONS  ON  FUNC- 
TIONAL NERVOUS  DISORDERS.  Second  Am- 
erican edition.  In  one  handsome  octavo  volume 
of  340  pages.   Cloth,  $3.25. 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,  etc.  19 


BOSS,  JAMBS,  M.JD.,  F.B.  C.F.,  LL.JD., 

Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 

A  Handbook  on  Diseases  of  the  Nervous  System.  In 
volume  of  725  pages,  with  184  illustrations.    Cloth,  $4.50 ;  leather,  $5.50 

This  admirable  work  is  intended  for  students  of 
medicine  and  for  such  medical  men  as  have  no  time 
for  lengthy  treatises.  In  the  present  instance  the 
duty  of  arranging  the  vast  store  of  material  at  the 
disposal  of  the  author,  and  of  abridging  the  de- 
scription of  the  different  aspects  of  nervous  dis- 
eases, has  been  performed  with  singular  skill,  and 
the  result  is  a  concise  and  philosophical  guide  to 


one  octavo 


the  department  of  medicine  of  which  it  treats. 
Dr.  Ross  holds  such  a  high  scientific  position  that 
any  writings  whicn  bear  his  name  are  naturally 
expected  to  have  the  impress  of  a  powerful  intel- 
lect. In  every  part  this  handbook  merits  the 
highest  praise,  and  will  no  doubt  be  found  of  the 
greatest  value  to  the  student  as  well  as  to  the  prac- 
titioner.— Edinburgh  Medical  Journal,  Jan.  1887. 


MITCHELL,  S.  WEIB,  M.  D., 

Physician  to  Orthopaedic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  System,  Phila.,  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  Women. 
Second  edition.    In  one  12mo.  volume  of  288  pages.    Cloth,  $1.75. 

teachings  the  stamp  of  authority  all  over  the 
realm  of  medicine.   The  work,  although  written 


No  work  in  our  language  develops  or  displays 
more  features  of  that  many-sided  affection,  hys- 
teria, or  gives  clearer  directions  for  its  differen- 
tiation, or  sounder  suggestions  relative  to  its 
general  management  and  treatment.  The  book 
is  particularly  valuable  in  that  it  represents  in 
the  main  the  author's  own  clinical  studies,  which 
have  been  so  extensive  and  fruitful  as  to  give  his 


by  a  specialist,  has  no  exclusive  character,  and 
the  general  practitioner  above  all  others  will  find 
its  perusal  profitable,  since  it  deals  with  diseases 
which  he  frequently  encounters  and  must  essay 
to  treat. — American  Practitioner,  August,  1885. 


HAMILTON,  ALLAN  McLANE,.  M.  JD., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackwelVs  Island,  N.  7. 
Nervous  Diseases ;  Their  Description  and  Treatment.    Second  edition,  thoroughly 
revised  and  rewritten.  In  one  octavo  volume  of  598  pages,  with  72  illustrations.  Cloth,  $4. 

When  the  first  edition  of  this  good  book  appeared 
we  gave  it  our  emphatic  endorsement,  and  the 
present  edition  enhances  our  appreciation  of  the 
book  and  its  author  as  a  safe  guide  to  students  of 
clinical  neurology.  One  of  the  best  and  most 
critical  of  English  neurological  journals,  Brain,  has 


characterized  this  book  as  the  best  of  its  kind  in 
any  language,  which  is  a  handsome  endorsement 
from  an  exalted  source.  The  improvements  in  the 
new  edition,  and  the  additions  to  it,  will  justify  its 
purchase  even  by  those  who  possess  the  old. — 
Alienist  and  Neurologist,  April,  1882. 


TUKJE,  DANIEL  HACK,  M.  JO., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  467  pages,  with 
two  colored  plates.    Cloth,  $3.00. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomena  the  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.— New  York  Medical  Journal,  September  6, 1884. 


CLOUSTON,  THOMAS  S.,  M.  D.,  F.  B.  C.  P.,  L.  B.  C.  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of.  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  volume  of  541 
pages,  with  eight  lithographic  plates,  four  of  which  are  beautifully  colored.    Cloth,  $4. 


The  practitioner  as  well  as  the  student  will  ac- 
cept the  plain,  practical  teaching  of  the  author  as  a 
forward  step  in  the  literature  of  insanity.  It  is 
refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  giving  the  bed- 
side notes  upon  which  his  experience  has  been 
founded  and  his  mature  judgment  established. 
Such  clinical  observations  cannot  but  be  useful  to 


the  general  practitioner  in  guiding  him  to  a  diag- 
nosis and  indicating  the  treatment,  especially  in 
many  obscure  and  doubtful  cases  of  mental  dis- 
ease. To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  make  it  a  desirable  addition  to  every  library. 
— American  Psychological  Journal,  July,  1884. 


J^jJ-Dr.  Folsom's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
108  pages.    Cloth,  $1.50. 

SAVAGE,  GEOBGE  H.,  M.  JD., 

Lecturer  on  Mental  Diseases  at  Guy's  Hospital,  London. 

Insanity  and  Allied  Neuroses,  Practical  and  Clinical.  In  one  12mo.  vol. 
of  551  pages,  with  18  illus.    Cloth,  $2.00.    See  Series  of  Clinked  Manuals,  page  4. 

JPLA  YFAIB,  W.  S.,  M.  D.,  F.  B.  C.  F. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.  In 

one  handsome  small  12mo.  volume  of  97  pages.    Cloth,  $1.00. 

Blandford  on  Insanity  and  its  Treatment:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.   In  one  very  handsome  octavo  volume. 


20 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


ASMJBUBST,  JOMW,  Jr.,  M.  JD., 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

The  Principles  and  Practice  of  Surgery.  New  (fourth)  edition,  enlarged 
and  revised.  In  one  large  and  handsome  octavo  volume  of  1114  pages,  with  597  illustra- 
tions.   Cloth,  $6 ;  leather,  $7 ;  half  Eussia,  $7.50. 


As  with  Eriehsen  so  with  Ashhurst,  its  position 
in  professional  favor  is  established,  and  one  has 
now  but  to  notice  the  changes,  if  any,  in  theory 
and  practice,  that  are  apparent  in  the  present 
as  compared  with  the  preceding  edition,  published 
three  years  ago.  The  work  has  been  brought  well 
up  to  date,  and  is  larger  and  better  illustrated  than 
before,  and  its  author  may  rest  assured  that  it  will 
certainly  have  a  "  continuance  of  the  favor  with 
which  it  has  heretofore  been  received."—  The 
American  Journal  of  the  Medical  Sciences,  Jan.  1886. 


Every  advance  in  surgery  worth  notice,  chroni- 
cled in  recent  literature,  has  been  suitably  recog- 
nized and  noted  ?.n  its  proper  place.  Suffice  it  to 
say,  we  regard  Ashhurst's  Surgery,  as  now  pre- 
sented in  the  fourth  edition,  as  the  best  single 
volume  on  surgery  published  in  the  English  lan- 
guage, valuable  alike  to  the  student  and  the  prac- 
titioner, to  the  one  as  a  text-book,  to  the  other  as 
a  manual  of  practical  surgery.  With  pleasure  we 
give  this  volume  our  endorsement  in  full.— New 
Orleans  Medical  and  Surgical  Journal,  Jan.,  1886. 


GB0S8,  S.  I).,  M,  D.,  LL.  JD.,  D.  C.  L.  Oxon.,  LL.  JO. 

Cantab., 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery:  Pathological,  Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.  ^  In  two  large  and  beautifully- 

grinted  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings, 
trongly  bound  in  leather,  raised  bands,  $15 ;  half  Eussia,  raised  bands,  $16. 
Dr.  Gross'  System  of  Surgery  has  long  been  the 
standard  work  on  that  subject  for  students  and 
practitioners. — London  Lancet,  May  10, 1884. 
The  work  as  a  whole  needs  no  commendation 


Many  years  ago  it  earned  for  itself  the  enviable 
reputation  of  the  leading  American  work  on  sur- 
gery, and  it  is  still  capable  of  maintaining  that 
standard.  A  considerable  amount  of  new  material 
has  been  introduced,  and  altogether  the  distin- 
guished author  has  reason  to  be  satisfied  that  he 
has  placed  the  work  fully  abreast  of  the  state  of 
our  knowledge.— Med.  Record,  Nov.  18, 1882. 


His  System  oj  Surgery,  which,  since  its  first  edi- 
tion in  1859,  has  been  a  standard  work  in  this 
country  as  well  as  in  America,  in  "the  whole 
domain  of  surgery,"  tells  how  earnest  and  labori- 
ous and  wise  a  surgeon  he  was.  how  thoroughly 
he  appreciated  the  work  done  by  men  in  other 
countries,  and  how  much  he  contributed  to  pro- 
mote the  science  and  practice  of  surgery  in  his 
own.  .  There  has  been  no  man  to  whom  America 
is  so  much  indebted  in  this  respect  as  the  Nestor 
of  surgery.— British  Medical  Journal,  May  10, 1884. 


b.  a  s. 


GOVLD,  A.  PEABCE,  M.  S.,  M.  B.,  JE 

Assistant  Surgeon  to  Middlesex  Hospital. 

Elements  of  Surgical  Diagnosis.   In  one  pocket-size  12mo.  volume  of  589 

pages.    Cloth,  $2.00.    See  Students'  Series  of  Manuals,  page  4. 

This  book  will  be  found  to  be  a  most  useful 
guide  for  the  hard-worked  practitioner.  Mr. 
Gould's  style  is  eminently  clear  and  precise,  and 
we  can  cordially  recommend  the  manual  as  being 
the  outcome  of  the  efforts  of  an  honest  and  thor- 
oughly practical  surgeon.— The  Medical  News,  Jan. 


24,  1885. 


This  is  a  capital  little  book,  written  by  a  prac- 
tical man  on  a  very  practical  subject.  The  topics 
are  very  systematically  and  succinctly  arranged, 


are  tersely  presented,  and  the  points  of  diagnosis 
very  intelligently  discussed.  It  will  be  found  to 
be  of  the  greatest  amount  of  help  both  to  teacher 
and  student.— Medical  Record,  Feb.  28,  1885. 


GIBNEY,  V.  P.,  M.  D., 

Surgeon  to  the  Orthopaedic  Hospital,  New  York,  etc. 

Orthopaedic  Surgery.  For  the  use  of  Practitioners  and  Students.  In  one  hand- 
some octavo  volume,  profusely  illustrated.  Preparing. 


DBJJITT,  BOBEBT,  M.  B.  C.  $.,  etc. 

The  Principles  and  Practice  of  Modern  Surgery.  From  the  eighth 
London  edition.   In  one  8vo.  volume  of  687  pages,  with  432  illus.   Cloth,  $4 ;  leather,  $5. 


BOBEBTS,  JOHN  B.,  A.  M.,  M.  Z>., 

Lecturer  on  Anatomy  and  on  Operative  Surgery  at  the  Philadelphia  School  of  Anatomy. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students 

and  Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  about 
500  pages,  with  many  illustrations.  Preparing. 

BELLAMY,  EDWABD,  F.  B.  C.  S., 

Surgeon  and  Lecturer  on  Surgery  at  Charing  Cross  Hospital,  London. 
Operative  Surgery.   Shortly.   See  Students'  Series  of  Manuals,  page  4. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OP 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.   Cloth,  $3.75. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth 
and  revised  American  from  the  last  Edinburgh 
edition.  In  one  large  8vo.  vol.  of  682  pages,  with 
364  illustrations.  Cloth,  $3.75. 


SKEY'S  OPERATIVE  SURGERY.  In  one  vol.  8yo. 
of  661  pages,  with  81  woodcuts.   Cloth,  $3.25. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
Americaen  from  the  third  Edinburgh  edition.  In 
one  8vo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  $3.75. 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


21 


ERICMSEW,  JOHN  E.,  F.  R.  S.,  F.  R.  C.  S., 

Professor  of  Surgery  in  University  College,  London,  etc. 
The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.    From  the  eighth  and  enlarged  English  edition.    In  two  large  and 
beautiful  octavo  volumes  of  2316  pages,  illustrated  with  984  engravings  on  wood. 
Cloth,  $9 ;  leather,  raised  bands,  $11 ;  half  Eussia,  raised  bands,  $12. 

In  noticing  the  eighth  edition  of  this  well- 
known  work,  it  would  appear  superfluous  to  say 
more  than  that  it  has,  like  its  predecessors,  been 
brought  fully  up  to  the  times,  and  is  in  conse- 
quence one  of  the  best  treatises  upon  surgery  that 
has  ever  been  penned  by  one  man.  We  nave  al- 
ways regarded  "The  Science  and  Art  of  Surgery" 
as  one  of  the  best  surgical  text-books  in  the 
English  language,  and  this  eighth  edition  only 
confirms  our  previous  opinion.  We  take  great 
pleasure  in  cordially  commending  it  to  our  read- 
ers.—  The  Medical  News,  April  11, 1885. 

After  being  before  the  profession  for  thirty 


years  and  maintaining  during  that  period  a  re- 
putation as  a  leading  work  on  surgery,  there  is  not 
much  to  be  said  in  the  way  of  comment  or  criti- 
cism. That  it  still  holds  its  own  goes  without  say- 
ing. The  author  infuses  into  it  his  large  experi- 
ence and  ripe  judgment.  Wedded  to  no  school, 
committed  to  no  theory,  biassed  by  no  hobby,  he 
imparts  an  honest  personality  in  his  observations, 
and  his  teachings  are  the  rulings  of  an  impartial 
judge.  Such  men  are  always  safe  guides,  and  their 
works  stand  the  tests  of  time  and  experience. 
Such  an  author  is  Erichsen,  and  such  a  work  is  his 
Surgery— Medical  Record,  Feb.  21, 1885. 


BRYANT,  THOMAS,  F.  R.  C.  S., 

Surgeon  and  Lecturer  on  Surgery  at  Guy's  Hospital,  London. 
The  Practice  Of  Surgery.    Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.    In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.    Cloth,  $6.50;  leather,  $7.50;  half  Eussia,  $8.00. 


The  fourth  edition  of  this  work  is  fully  abreast 
of  the  times.  The  author  handles  his  subjects 
with  that  degree  of  judgment  and  skill  which  is 
attained  by  years  of  patient  toil  and  varied  ex- 
perience. The  present  edition  is  a  thorough  re- 
vision of  those  which  preceded  it,  with  much  new 
matter  added.  His  diction  is  so  graceful  and 
logical,  and  his  explanations  are  so  lucid,  as  to 
place  the  work  among  the  highest  order  of  text- 


books for  the  medical  student.  Almost  every 
topic  in  surgery  is  presented  in  such  a  form  as  to 
enable  the  busy  practitioner  to  review  any  subject 
in  every-day  practice  in  a  short  time.  No  time  is 
lost  with  useless  theories  or  superfluous  verbiage. 
In  short,  the  work  is  eminently  clear,  logical  and 
practical. — Chicago  Medical  Journal  and  Examiner, 
April,  1886. 


By  the  same  Author. 
Diseases  of  the  Breast.  In  one  12mo.  volume.  Preparing.  See  Series  of  Clinical 
Manuals,  page  4.   

THIEVES,  FREDERICK,  F.  R.  C.  S., 

LTunterian  Professor  at  the  Royal  College  of  Surgeons  of  England. 
A  Manual  of  Surgery.    In  Treatises  by  Various  Authors.    In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.    Price  per  volume,  cloth,  $2.  See 
Students'  Series  of  Manuals,  page  4. 


We  have  here  the  opinions  of  thirty-three 
authors,  in  an  encyclopaedic  form  for  easy  and 
ready  reference.  The  three  volumes  embrace 
every  variety  of  surgical  affections  likely  to  be 
met  with,  the  paragraphs  are  short  and  pithy,  and 
the  salient  points  and  the  beginnings  of  new  sub- 
jects are  always  printed  in  extra-heavy  type,  so 
that  a  person  may  find  whatever  information  he 
may  be  in  need  of  at  a  moment's  glance.  The 
authors  have  confined  themselves  to  stating  only 
what  is  really  important  to  know,  free  from  all 
diffuseness  and  unnecessary  adornment. — Cincin- 
nati Lancet-Clinic,  August  21,  1886. 

The  hand  of  Mr.  Treves  is  evident  throughout 


in  the  choice,  arrangement  and  logical  sequence  of 
the  subjects.  Every  topic,  as  far  as  observed,  is 
treated  with  a  fulness  of  essential  detail,  which  is 
somewhat  surprising  in  view  of  the  necessary 
limitations  of  space.  Another  characteristic  of  the 
work  is  the  well-nigh  universal  acceptance  of  mod- 
ern and  progressive  views  of  pathology  and  treat- 
ment. The  entire  work  is  conceived  and  executed 
in  a  scientific  spirit.  It  is  conservative  without 
bigotry  and  contains  the  bone  and  marrow  of  mod- 
ern surgery.  Taking  the  manual  in  its  entirety, 
it  unquestionably  fills  a  place  in  the  surgeon's 
library  which  would  otherwise  be  untenanted. — 
Annals  of  Surgery,  Oct.  1886. 


BUTLIW,  HENRY  T.,  F.  R.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 

Diseases  of  the  Tongue.  In  one  12mo.  volume  of  456  pages,  with  8  colored 
plates  and  3  woodcuts.    Cloth,  $3.50.    See  Series  of  Clinical  Manuals,  page  4. 


Twenty-four  excellent  colored  lithographs,  illus- 
trating the  diseased  condition  of  the  organ  have 
been  added,  which  much  increase  the  value  of 
the  book.  Mr.  Butlin  has  written  a  work  of  great 
merit,  and  the  book  is  a  valuable  addition  to  sur- 
gical literature. — New  York  Medical  Journal,  July 
17,  1886. 

The  language  of  the  text  is  clear  and  concise. 


The  author  has  aimed  to  state  facts  rather  than  to 
express  opinions,  and  has  compressed  within  the 
compass  of  this  small  volume  the  pathology,  etiol- 
ogy, etc.,  of  diseases  of  the  tongue  that  are  incon- 
veniently scattered  through  general  works  on  sur- 
gery and  the  practice  of  medicine.  The  physician 
and  surgeon  will  appreciate  its  value  as  an  aid  and 
guide.— Physician  and  Surgeon,  Sept.  1886. 


TREVES,  FREDERICK,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  the  London  Hospital. 

Intestinal  Obstruction.  In  one  pocket-size  12mo.  volume  of  522  pages,  with  60 
illustrations.  Limp  cloth,  blue  edges,  $2.00.    See  Series  of  Clinical  Manuals,  page  4. 

A  standard  work  on  a  subject  that  has  not  been 
so  comprehensively  treated  by  any  contemporary 

full 


English  writer.   Its  completeness  renders  a 
review  difficult,  since  every  chapter  deserves  mi- 
nute attention,  and  it  is  impossible  to  do  thorough 


justice  to  the  author  in  a  few  paragraphs.  Intet- 
tinal  Obstruction  is  a  work  that  will  prove  of 


pr 

equal  value  to  the  practitioner,  the  student,  the 
pathologist,  the  physician  and  the  operating  sur- 
geon.— British  Medical  Journal,  Jan.  31, 1886. 


BALL,  CHARLES  B.,  M.  Clu,  Dub.,  F.  R.  C.  S.  E., 

Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital,  Dublin. 

Diseases  of  the  Rectum  and  Anus.  In  one  12mo.  volume  of  550  pages. 
Preparing.    See  Series  of  Clinical  Manuals,  page  4. 


22     Lea  Brothers  &  Co.'s  Publications — Surgery,  Frac,  Oisloc. 


HOLMES,  TIMOTHY,  M.  A., 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery;  Theoretical  and  Practical.   IN  TKEATISES  BY 

VAKIOUS  AUTHOKS.  American  edition,  thoroughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  and  very  handsome  imperial  octavo  volumes  containing  3137  double- 
columned  pages,  with  979  illustrations  on  wood  and  13  lithographic  plates,  beautifully 
colored.  Price  per  set,  cloth,  $18.00 ;  leather,  $21.00 ;  half  Kussia,  $22.50.  Sold  only  by 
subscription. 


HAMILTON,  FMAJVKH.,  M.  I).,  LL.  JD., 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.   Seventh  edition 

thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages,  with  379  illustrations.  Cloth,  $5.50 ;  leather,  $6.50 ;  very  handsome  half  Kussia, 
open  back,  $7.00 


It  is  about  twenty-five  years  ago  since  the  first 
edition  of  this  great  work  appeared.  The  edition 
now  issued  is  the  seventh,  and  this  fact  alone  is 
enough  to  testify  to  the  excellence  of  it  in  all  par- 
ticulars. Books  upon  special  subjects  do  not 
usually  command  extended  sale,  but  this  one  is 
without  a  rival  in  any  language.  It  is  essentially 
a  practical  treatise,  and  it  gathers  within  its  covers 
almost  everything  valuable  that  has  been  written 
about  fractures  and  dislocations.  The  principles 
and  methods  of  treatment  are  very  fully  given. 
The  book  is  so  well  known  that  it  does  not  require 


any  lengthened  review.  We  can  only  say  that  it 
is  still  unapproached  as  a  treatise,  and  that  it  is  a 
proof  of  the  zeal  and  industry  and  great  ability  of 
its  distinguished  author. —  The  Dublin  Journal  oj 
Medical  Science,  Feb.  1886. 

His  famous  treatise  on  Fractures  and  Disloca- 
tions, published  first  in  1860,  is  justly  regarded  as 
the  best  book  on  that  subject  in  existence.  It  has 
now  run  through  seven  editions,  and  has  been 
translated  into  French  and  German. — Medical 
Record,  Aug.  14,  1886. 


SMITH,  STEPHEN,  M.  H., 

Professor  of  .Clinical  Surgery  in  the  University  of  the  City  of  New  York. 

The  Principles  and  Practice  of  Operative  Surgery.  New  (second)  and 
thoroughly  revised  edition.  In  one  very  handsome  octavo  volume  of  892  pages,  with 
1005  illustrations.    Cloth,  $4.00;  leather,  $5.00.    Just  ready. 

This  work  is  too  well  and  too  favorably  known  to 
require  any  words  of  commendation,  and  its  mer- 
its effectually  protect  it  from  adverse  criticism. 
It  is  a  treatise  upon  the  principles  as  well  as  the 
practice  of  mechanical  surgery.   The  subject  mat- 


ter is  brought  down  to  the  very  latest  period,  hence 
we  shall  find  the  work  to  be  a  faithful  exponent 
of  the  art  of  surgery  as  practised  now.  Stephen 
Smith's  Operative  Surgery  is  one  of  the  most  com- 


plete works  in  the  English  language,  and  is  a  fit 
companion  to  Malgaigne's  magnificent  treatise. 
The  woodcuts  are  good,  and  are  very  numerous. 
The  descriptions  of  operative  procedures  are  plain, 
and  the  opinions  expressed  are  conservative  and 
judicious.  The  work  reflects  great  credit  upon  the 
author  and  upon  American  surgical  literature. — 
The  American  Journal  of  the  Medical  Sciences,  April, 
1887. 


STIMSON,  LEWIS  A.,  B.  A.,  M.  JO., 

Professor  of  Pathological  Anatomy  at  the  University  of  the  City  of  New  York,  Surgeon  and  Curator 
to  Bellevue  Hospital,  Surgeon  to  the  Presbyterian  Hospital,  New  York,  etc. 

A  Manual  of  Operative  Surgery.  New  (second)  edition.  In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.    Cloth,  $2.50.    Just  ready. 


There  is  always  room  for  a  good  book,  so  that 
while  many  works  on  operative  surgery  must  be 
considered  superfluous,  that  of  Dr.  Stimson  has 
held  its  own.  The  author  knows  the  difficult  art 
of  condensation.  Thus  the  manual  serves  as  a 
work  of  reference,  and  at  the  same  time  as  a 
handy  guide.  It  teaches  what  it  professes,  the 
steps  of  operations.  In  this  edition  Dr.  Stimson 
has  sought  to  indicate  the  changes  that  have  been 


effected  in  operative  methods  and  procedures  by 
the  antiseptic  system,  and  has  added  an  account 
of  many  new  operations  and  variations  in  the 
steps  of  older  operations.  We  do  not  desire  to 
extol  this  manual  above  many  excellent  standard 
British  publications  of  the  same  class,  still  we  be- 
lieve that  it  contains  much  that  is  worthy  of  imi- 
tation.— British  Medical  Journal,  Jan.  22, 1887. 


By  the  same  Author. 
A  Practical  Treatise  on  Fractures.   In  one  very  handsome  octavo  volume  of 
598  pages,  with  360  beautiful  illustrations.    Cloth,  $4.75 ;  leather,  $5.75. 


The  author  has  given  to  the  medical  profession 
in  this  treatise  on  fractures  what  is  likely  to  be- 
come a  standard  work  on  the  subject.  It  is  certainly 
not  surpassed  by  any  work  written  in  the  English, 
or,  for  that  matter,  any  other  language.  The  au- 
thor tells  us  in  a  short,  concise  and  comprehensive 
manner,  all  that  is  known  about  his  subject.  There 
is  nothing  scanty  or  superficial  about  it,  as  in  most 
other  treatises ;  on  the  contrary,  c  verything  is  thor- 


ough. The  chapters  on  repair  of  fractures  and  their 
treatment  show  him  not  only  to  be  a  profound  stu- 
dent, but  likewise  a  practical  surgeon  and  patholo- 
gist. His  mode  of  treatment  of  the  different  fract- 
ures is  eminently  sound  and  practical.  We  consider 
this  work  one  of  the  best  on  fractures ;  and  it  will 
be  welcomed  not  only  as  a  text-book,  but  also  by 
the  surgeon  in  full  practice.— N.  O.  Medical  and 
Surgical  Journal,  March,  1883. 


MABSH,  HOW  Ann,  F.  It.  C.  S., 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 

Diseases  of  the  Joints.   In  one  12mo.  volume  of  468  pages,  with  64  woodcuts 

and  a  colored  plate.    Cloth,  $2.00.    See  Series  of  Clinical-  Manuals,  page  4. 

PICK,  T.  PICKERING,  F.  M.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.  In  one  12mo.  volume  of  530  pages,  with  93 
illustrations.   Limp  cloth,  2.00.   See  Series  of  Clinical  Manuals,  page  4. 


Lea  Brothers  &  Co.'s  Publications — Otol.,  Ophtlial. 


23 


BURJSTETT,  CHARLES  II.,  A.  31.,  M.  D., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic;  President  of  the  American  Otological  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  New  (second)  edition.  In  one  handsome 
octavo  volume  of  580  pages,  with  107  illustrations.  Cloth,  $4.00 ;  leather,  $5.00. 

We  note  with  pleasure  the  appearance  of  a  second   carried  out,  and  much  new  matter 
edition  of  this  valuable  work.   When  it  first  came 


out  it  was  accepted  by  the  profession  as  one  of 
the  standard  works  on  modern  aural  surgery  in 
the  English  language;  and  in  his  second  edition 
Dr.  Burnett  has  fully  maintained  his  reputation, 
for  the  book  is  replete  with  valuable  information 
and  suggestions.   The  revision  has  been  carefully 


new  matter  added.  Dr. 
Burnett's  work  must  be  regarded  as  a  very  valua- 
ble contribution  to  aural  surgery,  not  only  on 
account  of  its  comprehensiveness,  but  because  it 
contains  the  results  of  the  careful  personal  observa- 
tion and  experience  of  this  eminent  aural  surgeon. 
— London  Lancet,  Feb.  21,  1885. 


FOLITZER,  ADAM, 

Imperials  Royal  Prof,  of  Aural  Therap.  in  the  Univ.  of  Vienna. 

A  Text-Book  of  the  Ear  and  its  Diseases.  Translated,  at  the  Author's  re- 
quest, by  James  Patterson  Cassells,  M.  D.,  M.  E.  C.  S.  In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.    Cloth,  $5.50. 


The  work  itself  we  do  not  hesitate  to  pronounce 
the  best  upon  the  subject  of  aural  diseases  which 
has  ever  appeared,  systematic  without  being  too 
diffuse  on  obsolete  subjects,  and  eminently  prac- 
tical in  every  sense.  The  anatomical  descriptions 
of  each  separate  division  of  the  ear  are  admirable, 
and  profusely  illustrated  "by  woodcuts.  They  are 
followed  immediately  by  the  physiology  of  the 


section,  and  this  again  by  the  pathological  physi- 
ology, an  arrangement  which  serves  to  keep  up  the 
interest  of  the  student  by  showing  the  direct  ap- 
plication of  what  has  preceded  to  the  study  of  dis- 
ease. The  whole  work  can  be  recommended  as  a 
reliable  guide  to  the  student,  and  an  efficient  aid 
to  the  practitioner  in  his  treatment. — Boston  Med- 
ical and  Surgical  Journal,  June  7, 1883. 


JULER,  HENRY  E.,  F.  R.  C.  $., 

Senior  Ass't  Surgeon, Royal  Westminster  Ophthalmic  Hosp. ;  late  Clinical  AssH,  Moorfields,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handsome 
octavo  volume  of  460  pages,  with  125  woodcuts,  27  colored  plates,  selections  from  the 
Test-types  of  Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test.  Cloth,  $4.50 ; 
leather,  $5.50. 


This  work  is  distinguished  by  the  great  num- 
ber of  colored  plates  which  appear  in  it  for  illus- 
trating various  pathological  conditions.  They  are 
very  beautiful  in  appearance,  and  have  been 
executed  with  great  care  as  to  accuracy.  An  ex- 
amination of  the  work  shows  it  to  be  one  of  high 
standing,  one  that  will  be  regarded  as  an  authority 
among  ophthalmologists.  The  treatment  recom- 
mended is  such  as  the  author  has  learned  from 
actual  experience  to  be  the  best. — Cincinnati  Medi- 
cal News,  Dec.  1884. 

It  presents  to  the  student  concise  descriptions 


and  typical  illustrations  of  all  important  eye 
affections,  placed  in  juxtaposition,  so  as  to  be 

§ rasped  at  a  glance.  Beyond  a  doubt  it  is  the 
est  illustrated  handbook  of  ophthalmic  science 
which  has  ever  appeared.  Then,  what  is  still 
better,  these  illustrations  are  nearly  all  original. 
We  have  examined  this  entire  work  with  great 
care,  and  it  represents  the  commonly  accepted 
views  of  advanced  ophthalmologists.  We  can  most 
heartily  commend  this  book  to  all  medical  stu- 
dents, practitioners  and  specialists.  —  Detroit 
Lancet,  Jan.  1885. 


Ophthalmic  Surgeon  to  and  Lecturer  on  Oph- 
thalmic Surgery  at  St.  George's  Hospital, 
London. 


MORRIS,  WM.  F.,  M.  D.,  and  OLIVER,  CHAS.  A.,  M.  D. 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 

A  Text-Book  of  Ophthalmology.  In  one  octavo  volume  of  about  500  pages, 
with  illustrations.  Preparing. 

CARTER,  R.  BRJIDENELL,  &  FROST,  W.  ADAMS, 

F.  R.  €.  S.,  F.  R.  C.  S., 

Assistant  Ophthalmic  Surgeon  to  and  Joint 
Lecturer  on  Ophthalmic  Surgery  at  St. 
George's  Hospital,  London. 

Ophthalmic  Surgery.  In  one  12mo.  volume  of  about  400  pages.  Preparing. 
See  Series  of  Clinical  Manuals,  page  4.   - 

WELLS,  J.  SOELBERG,  F.  R.  C.  S., 

Professor  of  Ophthalmology  in  Kinq's  College  Hospital,  London,  etc. 

A  Treatise  on  Diseases  of  the  Eye.  New  (fifth)  American  from  the  third 
London  edition.  Thoroughly  revised,  with  copious  additions,  by  L.  Webster  Fox,  M.  D. 
In  one  large  octavo  volume  of  about  850  pages,  with  about  275  illustrations  on  wood,  six 
colored  plates,  and  selections  from  the  Test-types  of  Jaeger  and  Snellen.  Preparing. 

NETTLESHIF,  EDWARD,  F.  R.  C.  S., 

Ophthalmic  Surg,  and  Led.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  Second  edition.  With  a  chap- 
ter on  the  Detection  of  Color-Blindness,  by  William  Thomson,  M.  D.,  Ophthalmologist 
to  the  Jefferson  Medical  College.  In  one  royal  12mo.  volume  of  416  pages,  with  138 
illustrations.    Cloth,  $2.00.   

BROWNE,  EDGAR  A., 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary  and  to  the  Dispensary  for  Skin  Diseases. 
How  to  Use  the  Ophthalmoscope.    Being  Elementary  Instructions  in  Oph- 
thalmoscopy, arranged  for  the  use  of  Students.    In  one  small  royal  12mo.  volume  of  116 
pages,  with  35  illustrations.    Cloth,  $1.00. 


LAURENCE  AND  MOON'S  HANDY  BOOK  OF 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac- 
titioners. Second  edition.  In  one  octavo  vol- 
ume of  227  pages,  with  65  illust.   Cloth,  $2.75. 


LAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
AND  EYELIDS:  Their  Immediate  and  Remote 
Effects.   8  vo.,  404  pp.,  92  illus.   Cloth,  $3.50. 


24   Lea  Brothers  &  Co.'s  Publications — Urin.  Dis.,  Dentistry,  etc. 


ROBERTS,  WILLIAM,  M.  D., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth.  American  from  the  fourth  London  edition.  In  one  hand- 
some octavo  volume  of  609  pages,  with  81  illustrations.    Cloth,  $3.50 

The  previous  editions  of  this  book  have  made  it 
so  familiar  to  and  so  highly  esteemed  by  the  med- 
ical public,  that  little  more  is  necessary  than  a 
mere  announcement  of  the  appearance  of  this, 
their  successor.  But  it  is  pleasant  to  be  able  to 
say  that,  good  as  those  were,  this  is  still  better. 
In  fact,  we  think  it  may  be  said  to  be  the  best  book 
in  print  on  the  subject  of  which  it  treats. — The 
American  Journal  of  the  Medical  Sciences. — Jan.  1886. 


The  peculiar  value  and  finish  of  the  book  are  in 
a  measure  derived  from  its  resolute  maintenance 
of  a  clinical  and  practical  character.  It  is  an  un- 
rivalled exposition  of  everything  which  relates 
directly  or  indirectly  to  the  diagnosis,  prognosis 
and  treatment  of  urinary  diseases,  and  possesses 
a  completeness  not  found  elsewhere  in  our  lan- 

?uage  in  its  account  of  the  different  affections. — 
Vie  Manchester  Medical  Chronicle,  July,  1885. 


FJJRDY,  CHARLES  W.,  M.  D. 
Bright's  Disease  and  Allied  Disorders. 

with  illustrations.    Cloth,  $2.  Just  ready. 


In  one  octavo  volume  of  288  pages, 


The  object  of  this  work  is  to  "  furnish  a  system- 
atic, practical  and  concise  description  of  the 

Sathology  and  treatment  of  the  chief  organic 
iseases  of  the  kidney  associated  with  albuminu- 
ria, which  shall  represent  the  most  recent  ad- 
vances in  our  knowledge  on  these  subjects  ; "  and 
this  definition  of  the  object  is  a  fair  description  of 
the  book.   The  work  is  a  useful  one,  giving  in  a 


short  space  the  theories,  facts  and  treatments,  and 
going  more  fully  into  their  later  developments. 
On  treatment  the  writer  is  particularly  strong, 
steering  clear  of  generalities,  and  seldom  omit- 
ting, what  text-books  usually  do,  the  unimportant 
items  which  are  all  important  to  the  general  prac- 
titioner.— The  Manchester  Medical  Chronicle,  Oct., 


MORRIS,  HENRY,  M.  B.,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Kidney.    In  one  12mo.  volume  of  554  pages,  with  40 

woodcuts,  and  6  colored  plates.  Limp  cloth,  $2.25.    See  Series  of  Clinical  Manuals,  page  4. 

In  this  manual  we  have  a  distinct  addition  to 
surgical  literature,  which  gives  information  not 
elsewhere  to  be  met  with  in  a  single  work.  Such 
Sk  book  was  distinctly  required,  and  Mr.  Morris 


has  very  diligently  and  ably  performed  the  task 


he  took  in  hand.  It  is  a  full  and  trustworthy 
book  of  reference,  both  for  students  and  prac- 
titioners in  search  of  guidance.  The  illustrations 
in  the  text  and  the  cnromo-lithographs  are  beau- 
tifully executed. — The  London  Lancet,Feb.  26, 1886. 


See  Seriet 


LUCAS,  CLEMENT,  M.  B.,  B.  S.,  F.  R.  C.  S., 

Senior  Assistant  Surgeon  to  Guy's  Hospital,  London. 

»  Diseases  of  the  Urethra.    In  one  12mo.  volume.  Preparing. 

of  Clinical  Manuals,  page  4. 

THOMPSON,  SIR  HENRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.    In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.    Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulse.   From  the  third  English  edition.   In  one  octavo  volume  of  359 
with  47  cuts  and  3  plates.    Cloth,  $3.50. 


THE  AMERICAN  SYSTEM  OF  DENTISTRY. 

In  Treatises  by  Various  Authors.  Edited  by  Wilbur  F.  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  anu  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  of 
about  1000  pages  each,  richly  illustrated.  Per  volume,  cloth,  $6;  leather,  $7;  half 
Morocco,  gilt  top,  $8.  Volume  I.,  containing  1015  pages,  with  6  plates  and  537  woodcuts, 
just  ready.     For  sale  by  subscription  only. ' 

^As  an  encyclopaedia  of  Dentistry  it  has  no  su-  doubtless  it  is),  to  mark  an  epoch  in  the  history  of 
perior.  It  should  form  a  part  of  every  dentist's  dentistry.  Dentists  will  be  satisfied  with  it  and 
library,  as  the  information  it  contains  is  of  the   proud  of  it — they  must.   It  is  sure  to  be  precisely 

greatest  value  to  all  engaged  in  the  practice  of  what  the  student  needs  to  put  him  and  keep  him 
entistry. — American  Journal  of  Dental  Science,   in  the  right  track,  while  the  profession  at  large 
September,  1886.  will  receive  incalculable  benefit  from  it. — Odonto- 

A  grand  system,  big  enough  and  good  enough   graphic  Jozvrnal,  Jan.  1887. 
and  handsome  enough  for  a  monument  (which 


COLEMAN,  A.,  L.  R.  C.  F.,  F.  R.  C.  S.,  Exam.  L.  D.  S., 

Senior  Dent.  Surg,  and  Lect.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hosp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellwagen,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  at  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.    Cloth,  $3.25. 

ESMARCH,  Dr.  FRIED  RICH, 

Professor  of  Surgery  at  the  University  of  Kiel,  etc. 

^  Early  Aid  in  Injuries  and  Accidents.  Five  Ambulance  Lectures.  Trans- 
lated by  H.  E.  H.  Princess  Christian.  In  one  handsome  small  12mo.  volume  of  109 
pages,  with  24  illustrations.    Cloth,  75  cents.  ^ 

BASHAM   ON  RENAL  DISEASES:  A  Clinical 
Guide  to  their  Diagnosis  and  Treatment. 


;al  I  one  l2mo.  vol.  of  304  pages,  with  21  Illustrations. 
In  |  Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Venereal,  Impotence.  25 
GROSS,  SAMUEL  W.,  A.*M.,  M.  D.,  LL.  D., 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College  of  Phila. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  New  (third)  edition,  thoroughly  revised.  In  one  very 
handsome  octavo  volume  of  163  pages,  with  16  illustrations.    Cloth,  $1.50.    Just  ready. 

FROM  THE  PREFACE  TO  THE  NEW  EDITION. 
The  rapid  exhaustion  of  two  large  editions  of  this  work,  the  favorable  comments 
which  it  has  received  from  the  periodical  press,  its  translation  into  the  Eussian  language, 
and  the  fact  that  it  has  been  out  of  print  for  several  months,  constitute  valid  evidence 
that  it  has  filled  the  void  for  which  it  was  originally  designed.  My  aim  has  been  to  sup- 
ply in  a  compact  form  practical  and  strictly  scientific  information,  especially  adapted  to 
the  wants  of  the  general  practitioner,  in  regard  to  a  class  of  common  and  grave  disorders, 
upon  the  correction  of  which  so  much  of  human  happiness  depends. 

BUMSTFAD,  F,  J.,         and  TAYLOR,  R.  W., 

M.  &.,  LL.  D.,  A.  M.,  M.  X>., 

Late  Professor  of  Venereal  Diseases  Surgeon  to  Charity  Hospital,  New  York,  Prof,  of 

at  the  College  of  Physicians  and  Venereal  and  Skin  Diseases  in  the  University  of 

Surgeons,  New  York,  etc.  Vermont,  Pres.  of  the  Am.  Dermatological  Ass'n. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  Fifth  edition,  revised  and  largely  re- 
written, by  Dr.  Taylor.  In  one  large  and  handsome  octavo  volume  of  898  pages  "with 
139  illustrations,  and  thirteen  chromo-lithographic  figures.  Cloth,  $4.75;  leather,  $5.75; 
very  handsome  half  Kussia,  $6.25. 


It  is  a  splendid  record  of  honest  labor,  wide 
research,  just  comparison,  careful  scrutiny  and 
original  experience,  which  will  always  be  held  as 
a  high  credit  to  American  medical  literature.  This 
is  not  only  the  best  work  in  the  English  language 
upon  the  subjects  of  which  it  treats,  but  also  one 
which  has  no  equa^  in  other  tongues  for  its  clear, 
comprehensive  and  practical  handling  of  its 
themes. — American  Journal  of  the  Medical  Sciences, 
Jan,  1884. 

It  is  certainly  the  best  single  treatise  on  vene- 
real in  our  own,  and  probably  the  best  in  any  lan- 
guage.— Boston  Medical  and  Surgical  Journal,  April 
3, 1884. 


The  character  of  this  standard  work  is  so  well 
known  that  it  would  be  superfluous  here  to  pass  in 
review  its  general  or  special  points  of  excellence. 
The  verdict  of  the  profession  has  been  passed;  it 
has  been  accepted  as  the  most  thorough  and  com- 
plete exposition  of  the  pathology  and  treatment  of 
venereal  diseases  in  the  language.  Admirable  as  a 
model  of  clear  description,  an  exponent  of  sound 
pathological  doctrine,  and  a  guide  for  rational  and 
successful  treatment,  it  is  an  ornament  to  the  medi- 
cal literature  of  this  country.  The  additions  made 
to  the  present  edition  are  eminently  judicious, 
from  the  standpoint  of  practical  utility. — Journal  of 
Cutaneous  and  Venereal  Diseases,  Jan.  1884. 


CORNIL,  r.9 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lourcine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  William  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  of  Pennsylvania.  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.    Cloth,  $3.75. 

the  whole  volume  is  the  clinical  experience  of  the 
author  or  the  wide  acquaintance  of  the  translators 
with  medical  literature  more  evident.  The  anat- 
omy, the  histology,  the  pathology  and  the  clinical 
features  of  syphilis  are  represented  in  this  work  in 
their  best,  most  practical  and  most  instructive 
form,  and  no  one  will  rise  from  its  perusal  without 
the  feeling  that  his  grasp  of  the  wide  and  impor- 
tant subject  on  which  it  treats  is  a  stronger  and 
surer  one. —  The  London  Practitioner,  Jan.  1882. 


The  anatomical  and  histological  characters  of  the 
hard  and  soft  sore  are  admirably  described.  The 
multiform  cutaneous  manifestations  of  the  disease 
are  dealt  with  histologically  in  a  masterly  way,  as 
we  should  indeed  expect  them  to  be,  and  the 
accompanying  illustrations  are  executed  carefully 
and  well.  The  various  nervous  lesions  which  are 
the  recognized  outcome  of  the  syphilitic  dyscrasia 
are  treated  with  care  and  consideration.  Syphilitic 
epilepsy,  paralysis,  cerebral  syphilis  and  locomotor 
ataxia  are  subjects  full  of  interest;  and  nowhere"  in 


HUTCHINSON,  JONATHAN,  F.  R.  S.,  F.  R.  C.  S., 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.    In  one  12mo.  volume.    Shortly.    See  Series  of  Clinical  Manuals,  page  4. 

GROSS,  S.  &.,  M.  D.,  LL.  D.,  JD.  C.  L.,  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thoroughly  revised  by  Samuel  W.  Gross,  M.  D.  In  one  octavo  volume  of  574 
pages,  with  170  illustrations.    Cloth,  $4.50. 

CULLFRIFR,  A.,  &  B UMSTFAD,  F.  J.,  M.D.,  LL.JD., 

Surgeon  to  the  H6pital  du  Midi.       Late  Professor  of  Venereal  Diseases  in  the  College  of  Physicians 

and  Surgeons,  New  York. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Freeman  J.  Bum- 
stead,  M.  D.  In  one  imperial  4to.  volume  of  328  pages,  double-columns,  with  26  plates, 
containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of  life.  Strongly 
bound  in  cloth,  $17.00.  A  specimen  of  the  plates  and  text  sent  by  mail,  on  receipt  of  25  cts. 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  I  FORMS  OF    LOCAL    DISEASE  AFFECTING 
DISORDERS.  In  o*a8vo  vol.  of 479  p.  Cloth,  $3.25.   PRINCIPALLY  THE  ORGANS  OF  GENERA- 
LEE'S  LECTURES  ON  SYPHILIS  AND  SOME  TION.   In  one  8vo.  vol.  of  246  pages.   Cloth,  $2.26. 


26 


Lea  Brothers  &  Co.'s  Publications — Diseases  of  Skin. 


HYDE,  J.  KEVINS,  A.  M.,  M.  D., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Bush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  and 

Practitioners.  In  one  handsome  octavo  volume  of  570  pages,  with  66  beautiful  and  elab- 
orate illustrations.    Cloth,  $4.25 ;  leather,  $5.25. 


The  author  has  given  the  student  and  practi- 
tioner a  work  admirably  adapted  to  the  wants  of 
each.  We  can  heartily  commend  the  book  as  a 
valuable  addition  to  our  literature  and  a  reliable 
guide  to  students  and  practitioners  in  their  studies 
and  practice. — Am.  Journ.  of  Med.  Sci.,  July,  1883. 

The  aim  of  the  author  has  been  to  present  to  his 
readers  a  work  not  only  expounding  the  most 
modern  conceptions  of  his  subject,  but  presenting 
what  is  of  standard  value.  He  has  more  especially 
devoted  its  pages  to  the  treatment  of  disease,  and 
by  his  detailed  descriptions  of  therapeutic  meas- 
ures has  adapted  them  to  the  needs  of  the  physi- 
cian in  active  practice.  In  dealing  with  these 
questions  the  author  leaves  nothing  to  the  pre- 
.  sumed  knowledge  of  the  reader,  but  enters  thor- 
oughly into  the  most  minute  description,  so  that 
one  is  not  only  told  what  should  be  done  under 
given  conditions  but  how  to  do  it  as  well.  It  is 
therefore  in  the  best  sense  "  a  practical  treatise." 
That  it  is  comprehensive,  a  glance  at  the  index 
will  show. — Maryland  Medical  Journal,  July  7,  1883. 

Professor  Hyde  has  long  been  known  as  one  of 
the  most  intelligent  and  enthusiastic  representa- 
tives of  dermatology  in  the  west.  His  numerous 
contributions  to  the  literature  of  this  specialty 
have  gained  for  him  a  favorable  recognition  as  a 
careful,  conscientious  and  original  observer.  The 
remarkable  advances  made  in  our  knowledge  of 
diseases  of  the  skin,  especially  from  the  stand- 
point of  pathological  histology  and  improved 
methods  of  treatment,  necessitate  a  revision  of 


the  older  text-books  at  short  intervals  in  order  to 
bring  them  up  to  the  standard  demanded  by  the 
march  of  science.  This  last  contribution  of  Dr. 
Hyde  is  an  effort  in  this  direction.  He  has  at- 
tempted, as  he  informs  us,  the  task  of  presenting 
in  a  condensed  form  the  results  of  the  latest  ob- 
servation and  experience.  A  careful  examination 
of  the  work  convinces  us  that  he  has  accomplished 
his  task  with  painstaking  fidelity  and  with  a  cred- 
itable result.— Journal  of  Cutaneous  and  Venereal 
Diseases,  June,  1883. 

Prof.  Hyde  has  given  to  the  profession  a  valuable 
and  comprehensive  work  upon  this  special  subject 
— exposing  the  etiology,  symptomatology  and  treat- 
ment of  diseases  of  *the  skin  in  a  concise  and 
thorough  manner.  The  book  is  a  valuable  one  for 
the  student  and  practitioner,  containing  all  the 
latest  progress  made  in  dermatology,  and  will, 
without  doubt,  attain  the  end  expected  by  its  au- 
thor—to make  the  general  practitioner  thoroughly 
informed  in  regard  to  the  treatment  of  cutaneous 
diseases;  and  it  will  prove  a  valuable  book  of  ref- 
erence to  the  specialist.— New  Orleans  Medical  and 
Surgical  Journal,  April,  1883. 

The  several  diseases  are  described  very  con- 
cisely, but  at  the  same  time  with  unusual  clear- 
ness. The  treatment  is  given  in  the  simplest  man- 
ner and  apparently  with  great  honesty.  It  is  a 
good  book,  remarkably  adapted  to  the  needs  of 
those  for  whom  it  was  written.  It  should  be  at 
once  placed  in  the  library  of  every  general  practi- 
tioner.—Detroit  Lancet,  April,  1883. 


FOX,  T.9  M.D.,  F.B.  C.  P.,  and  FOX,  T.  C,  B.A.,  M.B.  C.S., 


Physician  to  the  Department  for  Skin  Diseases, 
University  College  Hospital,  London. 


Physician  for  Diseases  of  the  Skin  to  the 
Westminster  Hospital,  London. 


An  Epitome  of  Skin  Diseases.  With  Formulae.  For  Students  and  Prac- 
titioners.   Third  edition,  revised  and  enlarged.    In  one  very  handsome  12mo.  volume 

of  238  pages.    Cloth,  $1.25. 


The  third  edition  of  this  convenient  handbook 
calls  for  notice  owing  to  the  revision  and  expansion 
which  it  has  undergone.  The  arrangement  of  skin 
diseases  in  alphabetical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 
to  students  but  also  to  practitioners  who  require  a 
compendious  summary  of  the  present  state  of 
dermatology. — British  Medical  Journal,  July  2, 1883. 

We  cordially  recommend  Fox's  Epitome  to  those 
whose  time  is  limited  and  who  wish  a  handy 


manual  to  lie  upon  the  table  for  instant  reference. 
Its  alphabetical  arrangement  is  suited  to  this  use, 
for  all  one  has  to  know  is  the  name  of  the  disease, 
and  here  are  its  description  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  has  been  very  carefully 
revised  and  a  number  of  new  diseases  are  de- 
scribed, while  most  of  the  recent  additions  to 
dermal  therapeutics  find  mention,  and  the  formu- 
lary at  the  end  of  the  book  has  been  considerably- 
augmented. —  The  Medical  News,  December,  1883. 


M'OMMIS,  MALCOLM,  F.  M.  C.  S., 

Joint  Lecturer  on  Dermatology  at  St.  Mary's  Hospital  Medical  School,  London. 
Skin  Diseases ;  Including  their  Definitions,  Symptoms,  Diagnosis,  Prognosis,  Mor- 
bid Anatomy  and  Treatment.   A  Manual  for  Students  and  Practitioners.    In  one  12mo. 
volume  of  316  pages,  with  illustrations.    Cloth,  $1.75. 


To  physicians  who  would  like  to  know  something 
about  skin  diseases,  so  that  when  a  patient  pre- 
sents himself  for  relief  they  can  make  a  correct 
diagnosis  and  prescribe  a  rational  treatment,  we 
unhesitatingly  recommend  this  little  book  of  Dr. 
Morris.  The  affections  of  the  skin  are  described 
in  a  terse,  lucid  manner,  and  their  several  charac- 
teristics so  plainly  set  forth  that  diagnosis  will  be 
easy.  The  treatment  in  each  case  is  such  as  the 
experience  of  the  mosteminent  dermatologists  ad- 
vises.— Cincinnati  M edical  News,  April,  1880. 

This  is  emphatically  a  learner's  book;  for  we 
can  safely  say,  that  in  the  whole  range  of  medical 
literature  there  is  no  book  of  a  like  scope  which 


for  clearness  of  expression  and  methodical  ar- 
rangement is  better  adapted  to  promote  a  rational 
conception  of  dermatology— a  branch  confessedly 
difficult  and  perplexing  to  the  beginner. — St.  Louit 
Courier  of  Medicine,  April,  1880. 

The  writer  has  certainly  given  in  a  small  compass 
a  large  amount  of  well-compiled  information,  and 
his  little  book  compares  favorably  with  any  other 
which  has  emanated  from  England,  while  in  many 
points  he  has  emancipated  himself  from  the  stub- 
bornly adhered  to  errors  of  others  of  his  country- 
men. There  is  certainly  excellent  material  in  the 
book  which  will  well  repay  perusal. — Boston  Med. 
and  Surg.  Journ.,  March,  1880. 


WILSON,  FMASMUS,  F.B.S. 

The  Student's  Book  of  Cutaneous  Medicine  and  Diseases  of  the  Skin. 

In  one  handsome  small  octavo  volume  of  535  pages.  '  Cloth,  $3.50. 

HILLIEB,  THOMAS,  M.  D.,        ~  ' 

Physician  to  the  Skin  Department  of  University  College,  London. 
Handbook  of  Skin  Diseases;  for  Students  and  Practitioners.   Second  Ameri- 
can edition.    In  one  12mo.  volume  of  353  pages,  with  plates.    Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications — I>is.  of  Women. 


27 


The  American  Systems  of  Gynecology  and  Obstetrics, 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors.  Gynecology  edited  by  Matthew  D.  Mann,  A.  M.,  M.  D.,  Professor  of  Obstetrics 
and  Gynecology  in  the  Medical  Department  of  the  University  of  Buffalo;  and  Obstet- 
rics edited  by  Barton  Cooke  Hirst,  M.  D.,  Obstetrician  to  the  Philadelphia  and  to  the 
Maternity  Hospitals,  Philadelphia.  In  four  very  handsome  octavo  volumes  of  about  900 
pages  each,  fully  illustrated  by  wood  engravings  and  colored  plates.  Volume  I.,  in  a  few  days. 
For  sale  by  subscription  only.  Address  the  Publishers. 
Full  descriptive  circular  free  on  application. 

LIST  OF  CONTRIBUTORS. 


WILLIAM  H.  RAKER,  M.  D., 

FORDYCE  BARKER,  M.  D.,  LL.  D.,  Edin. 

ROBERT  BATTEY,  M.  D., 

SAMUEL  C.  BUSEY,  M.  D., 

JAMES  C.  CAMERON,  M.  D., 

HENRY  C.  COE,  A.  M  ,  M.  D., 

E.  C.  DUDLEY,  A.  B.,  M.  D., 

EDWARD  S.  DUNSTER,  M.  D.. 

B.  McE.  EMMET,  M.  D., 

GEORGE  J.  ENGELMANN,  M.  D., 

HAROLD  C.  ERNST,  M.  D., 

HENRY  J.  GARR1GUES,  A.  M.,  M.  D., 

WILLIAM  GOODELL,  A.  M.,  M.  D., 

EGBERT  H.  GRANDIN,  A.  M.,  M.  D., 

CHARLES  M.  GREEN,  M.  D., 

SAMUEL  W.  GROSS,  M.  D., 

ROBERT  P.  HARRIS,  M.  D., 

STEPHEN  Y.  HOWELL,  M.  D., 

JAMES  B.  HUNTER,  M.  D., 

A.  REEVES  JACKSON,  A.  M.,  M.  D., 

EDWARD  W.  JENKS,  M.  D.,  LL.  D., 

JOSEPH  TABER  JOHNSON,  M.  D., 


WILLIAM  T.  LUSK,  M.  D.,  LL.  D., 
MATTHEW  D.  MANN,  A.  M.,  M.  D., 
H.  NEWELL  MARTIN,  F.  R.  8..  M.  D., 

D.Sc,  M.A., 
RICHARD  B.  MAURY,  M.D., 
PAUL  F.  MUNDE,  M.  D., 
C.  D.  PALMER,  M.  D.,  « 
ROSWELL  PARK,  M.  D., 
THEOPHILUS  PARVIN,  M.  D.,  LL.  D.t 
R.  A.  F.  PENROSE,  M.  D.,  LL  D., 
WILLIAM  M.  POLK,  M.  D., 
THADDEUS  A.  REAMY,  A.  M.,  M.  D., 
J.  C.  REEVE,  M.  I)., 
WILLIAM  L.  RICHARDSON,  M.  D., 
A.  D.  ROCKWELL,  A.  M.,  M.  D., 
ALEXANDER  J.  C.  SKENE,  M.  D., 
J.  LEWIS  SMITH,  M.  D., 
R.  STANSBURY  SUTTON,  A.  M.,  M.  D., 

LL.  D., 

T.  GAILLARD  THOMAS,  M.  D.,  LL.  D., 
ELY  VAN  DE  WARKER,  M.  D., 
W.  GILL  WYLIE,  M.  D. 


THOMAS,  T.  GAILLABD,  M.  !>., 

Professor  of  Diseases  of  Women  in  the  College  of  Physicians  and  Surgeons,  N.  7. 

A  Practical  Treatise  on  the  [Diseases  of  "Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  handsome  octavo  volume  of  810  pages,  with  266 
illustrations.    Cloth,  $5.00 ;  leather,  $6.00 ;  very  handsome  half  Eussia,  raised  bands,  $6.50. 

The  words  which  follow  "fifth  edition"  are  in 
this  case  no  mere  formal  announcement.  The 


alterations  and  additions  which  have  been  made  are 
both  numerous  and  important.  The  attraction 
and  the  permanent  character  of  this  book  lie  in 
the  clearness  and  truth  of  the  clinical  descriptions 
of  diseases;  the  fertility  of  the  author  in  thera- 

Seutic  resources  and  the  fulness  with  which  the 
etails  of  treatment  are  described;  the  definite 
character  of  the  teaching;  and  last,  but  not  least, 
the  evident  candor  which  pervades  it.  We  would 
also  particularize  the  fulness  with  which  the  his- 
tory of  the  subject  is  gone  into,  which  makes  the 
book  additionally  interesting  and  gives  it  value  as 
a  work  of  reference. — London  Medical  Times  and 
Gazette,  July  30,  1881. 

The  determination  of  the  author  to  keep  his 
book  foremost  in  the  rank  of  works  on  gynecology 


is  most  gratifying.  Recognizing  the  fact  that  this 
can  only  be  accomplished  by  frequent  and  thor- 
ough revision,  he  has  spared  no  pains  to  make  the 
present  edition  more  desirable  even  than  the  pre- 
vious one.  As  a  book  of  reference  for  the  busy 
practitioner  it  is  unequalled. — Boston  Medical  and 
Surgical  Journal,  April  7, 1880. 

That  the  previous  editions  of  the  treatise  of  Dr. 
Thomas  were  thought  worthy  of  translation  into 
German,  French,  Italian  and  Spanish,  is  enough 
to  give  it  the  stamp  of  genuine  merit.  At  home  it 
has  made  its  way  into  the  library  of  every  obstet- 
rician and  gynaecologist  as  a  safe  guide  to  practice. 
No  small  number  of  additions  have  been  made  to 
the  present  edition  to  make  it  correspond  to  re- 
cent improvements  in  treatment.— Pacific  Medical 
and  Surgical  Journal,  Jan.  1881. 


M1>IS,  ABTJU7B  W.,  3f.  D.,  Lond.,  F.B.  CP.,  31.  B.  C.S., 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 
The  Diseases  of  Women.    Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.    A  Manual  for  Students  and  Practitioners.    In  one  handsome 
octavo  volume  of  576  pages,  with  148  illustrations.    Cloth,  $3.00 ;  leather,  $4.00. 

The  greatest  pains  have  been  taken  with  the 


It  is  a  pleasure  to  read  a  book  so  thoroughly 
good  as  this  one.  The  special  qualities  which  are 
conspicuous  are  thoroughness  in  covering  the 
whole  ground,  clearness  of  description  and  con- 
ciseness of  statement.  Another  marked  feature  of 
the  book  is  the  attention  paid  to  the  details  of 
many  minor  surgical  operations  and  procedures, 
as,  for  instance,  the  use  of  tents,  application  of 
leeches,  and  use  of  hot  water  injections.  These 
are  among  the  more  common  methods  of  treat- 
ment, and  yet  very  little  is  said  about  them  in 
many  of  the  text-books.  The  book  is  one  to  be 
warmly  recommended  especially  to  students  and 
general  practitioners,  who  need  a  concise  but  com- 
plete resume"  of  the  whole  subject.  Specialists,  too, 
will  find  many  useful  hints  in  its  pages. — Boston 
Med.  and  Surg.  Journ.,  March  2,  1882. 


sections  relating  to  treatment.  A  liberal  selection 
of  remedies  is  given  for  each  morbid  condition,, 
the  strength,  mode  of  application  and  other  details 
being  fully  explained.  The  descriptions  of  gyne- 
cological manipulations  and  operations  are  full, 
clear  and  practical.  Much  care  has  also  been  be- 
stowed on  the  parts  of  the  book  which  deal  with 
diagnosis— we  note  especially  the  pages  dealing 
with  the  differentiation,  one  from  another,  of  the 
different  kinds  of  abdominal  tumors.  The  prac- 
titioner will  therefore  find  in  this  book  the  kind 
of  knowledge  he  most  needs  in  his  daily  work,  and 
he  will  be  pleased  with  the  clearness  and  fulness 
of  the  information  there  given. —  The  Practitioner, 
Feb.  1882. 


BABJTES,  BOBE11T,  31.  I).,  F.  B.  C.  B.9 

Obstetric  Physician  to  St.  Thomas'  Hospital,  London,  etc. 

A  Clinical  Exposition  of  the  Medical  and  Surgical  Diseases  of  Women. 

In  one  handsome  octavo  volume,  with  numerous  illustrations.   New  edition.  Preparing. 

WEST,  CHABLES,  31.  D. 

Lectures  on  the  Diseases  of  Women.  Third  American  from  the  third  Lon- 
don edition.   In  one  octavo  volume  of  543  pages.   Cloth,  $3.75 ;  leather,  $4.75. 


23 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women,  Midwfy. 


EMMET,  THOMAS  ADDIS,  M.  D.,  LL.  D., 

Surgeon  to  the  Woman's  Hospital,  New  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  Medici  ne.  New  (third)  edition,  thorou  ghly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  $5;  leather,  $6; 
very  handsome  half  Eussia,  raised  bands,  $6.50. 

We  are  in  doubt  whether  to  congratulate  the 
author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  work. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  himself 
as  a  bold  and  successful  operator,  and  who  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 
the  privilege  thus  offered  them  of  perusing  the 
views  and  practice  of  the  author.  His  earnestness 
of  purpose  and  conscientiousness  are  manifest, 


He  gives  not  onl^his  individual  experience  but 
endeavors  to  represent  the  actual  state  of  gynae- 
cological science  and  art. — British  Medical  Jour- 
nal, May  16, 1885. 

No  jot  or  tittle  of  the  high  praise  bestowed  upon 
the  first  edition  is  abated.  It  is  still  a  book  of 
marked  personality,  one  based  upon  large  clinical 
experience,  containing  large  and  valuable  ad- 
ditions to  our  knowledge,  evidently  written  not 
only  with  honesty  of  purpose,  but  with  a  conscien- 
tious sense  of  responsibility,  and  a  book  that  is  at 


once  a  credit  to  its  author  and  to  American  med- 
ical literature.  We  repeat  that  it  is  a  book  to  be 
studied,  and  one  that  is  indispensable  to  every 
practitioner  giving  any  attention  to  gynecology. — 
American  Journal  of  the  Medical  Sciences,  April,  1885. 

The  time  has  passed  when  Emmet's  Gynaecology 
was  to  be  regarded  as  a  book  for  a  single  country 
or  for  a  single  generation.  It  has  always  been  his 
aim  to  popularize  gynecology,  to  bring  it  within 
easy  reach  of  the  general  practitioner.  The  orig- 
inality of  the  ideas,  aside  from  the  perfect  con- 
fidence which  we  feel  in  the  author's  statements, 
compels  our  admiration  and  respect.  We  may 
well  take  an  honest  pride  in  Dr.  Emmet's  work 
and  feel  that  his  book  can  hold  its  own  against  the 
criticism  of  two  continents.  It  represents  all  that 
is  most  earnest  and  most  thoughtful  in  American 
gynecology.  Emmet's  work  will  continue  to 
reflect  the  individuality,  the  sterling  integrity  and 
the  kindly  heart  of  its  honored  author  long  after 
smaller  books  have  been  forgotten. — American 
Journal  of  Obstetrics,  May,  1885. 


DUNCAJST,  J.  MATTHEWS,  M.D.,  LL.  D.,  I.  M.  S.  E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.   In  one  handsome  octavo  volume  of  175  pages.   Cloth,  $1.50. 
They  are  in  every  way  worthy  of  their  author 


indeed,  we  look  upon  them  as  among  the  most 
valuable  of  his  contributions.  They  are  all  upon 
matters  of  great  interest  to  the  general  practitioner. 
Some  of  them  deal  with  subjects  that  are  not,  as  a 


rule,  adequately  handled  in  the  text-books ;  others 
of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 
stamp  of  individuality  that  they  deserve  to  be 
widely  read. — N.  Y.  Medical  Journal,  March,  1880. 


MAY,  CHARLES  H.,  M.  D. 

Late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York. 

A  Manual  of  the  Diseases  of  Women.  Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynsecologv.  In  one  12mo.  volume  of  342  pages. 
Cloth,  $1.75. 


Medical  students  will  find  this  work  adapted  to 
their  wants.  Also  practitioners  of  medicine  will 
find  it  exceedingly  convenient  to  consult  for  the 
purpose  of  refreshing  their  minds  upon  the  lead- 
ing points  of  a  gynecological  subject.  By  syste- 
matic condensation,  the  omission  of  disputed  ques- 


tions, and  the  presentation  only  of  accepted  views, 
it  constitutes  a  very  satisfactory  exposition  of  the 
leading  principles  of  gynecology  as  they  are  un- 
derstood at  the  present  time. — Cincinnati  Medical 
News,  Nov.  1885. 


HODGE,  HUGH  L.,  M.  D., 

Emeritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 

On  Diseases  Peculiar  to  Women;  Including  Displacements  of  the  Uterus. 

Second  edition,  revised  and  enlarged.  In  one  beautifully  printed  octavo  volume  of  519 
pages,  with  original  illustrations.    Cloth,  $4.50. 

By  the  Same  Author. 

The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  numerous  wood- 
cuts. In  one  large  quarto  volume  of  542  double-columned  pages.  Strongly  bound  in 
cloth,  $14.00.  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address, 
free  by  mail,  on  receipt  of  six  cents  in  postage  stamps. 

BAMSBOTHAM,  FMAWCIS  H.,  M.  D. 

The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery; 

In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly  revised 
by  the  Author.  With  additions  by  W.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.    Strongly  bound  in  leather,  with  raised  bands,  $7. 

WINCKEL,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.  Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  by  J.  R.  Chadwick,  M.  D.    Octavo  484  pages.    Cloth,  $4.00. 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE 
DISEASES  PECULIAR  TO  WOMEN.  Third 
American  from  the  third  and  revised  London 
edition.   In  one  8vo.  vol.,  pp.  520.   Cloth,  $3.50. 

CHURCHILL  ON  THE  PUERPERAL  FEVER 


AND  OTHER  DISEASES  PECULIAR  TO  WO- 
MEN. In  one  8vo.  vol.  of  464  pages.  Cloth,  $2.50. 
MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  In  one  8vo. 
volume  of  346  pages.   Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Miawifery. 


29 


BARVIN,  TMEOBMILVS,  M.  B.,  LL.  B., 

Prof,  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jefferson  Med.  Coll.,  Phila. 

The  Science  and  Art  of  Obstetrics.  In  one  handsome  8vo.  volume  of  697 
pages,  with  214  engravings  and  a  colored  plate.    Cloth,  $4.25 ;  leather,  $5.25.  Just  ready. 

There  is  not  in  the  language  a  treatise  on  the 
subject  which  so  completely  and  intelligently 
gleans  the  whole  field  of  obstetric  literature,  giv- 
ing the  reader  the  winnowed  wheat  in  concise  and 
well-jointed  phrase,  in  language  of  exceptional 
purity  and  strength.  A  thorough  student  always, 
a  close  observer  from  a  practising  standpoint  for 
a  third  of  a  century,  and  a  critical  teacher  for  a 
score  of  years,  Prof.  Parvin  has  conscientiously 
devoted  the  accomplishments  of  his  culture  to 
the  preparation  of  his  book,  and  his  readers  will 


have  the  benefit  of  a  work  full  of  the  riches  of 
an  erudite  author  inspired  with  his  labor,  and 
wisely  wedded  to  the  truth  therein  as  he  sees  it. 
The  arrangement  of  the  matter  of  this  work  is 
unique  and  exceedingly  favorable  for  an  agreeable 
unfolding  of  the  science  and  art  of  obstetrics. 
This  new  book  is  the  easy  superior  of  any  single 
work  among  its  predecessors  for  the  student  or 
practitioner  seeking  the  best  thought  of  the  day 
in  this  department  of  medicine. — The  American 
Practitioner  and  News,  April  2,  1887. 


BARNES,  ROBERT,  M.  B.,  and  FANCOURT,  M.  B.9 

Phys.  to  the  General  Lying-in  Hosp.,  Lond.  Obstetric  Phys.  to  St.  Thomas'  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.  In  one  handsome  octavo  volume  of  872  pages,  with  231  illus- 
trations. Cloth,  $5 ;  leather,  $6. 


This  system  will  be  eagerly  sought  for,  not  only 
on  account  of  its  intrinsic  merit,  but  also  because 
the  reputation  which  the  elder  Barnes,  in  particu- 
lar, has  secured,  carries  with  it  the  conviction  that 
any  book  emanating  from  him  is  necessarily  sound 
in  teaching  and  conservative  in  practice.  It  is  in- 
deed eminently  fitting  that  a  man  who  has  done  so 
much  towards  systematizing  the  obstetric  art,  who 
for  so  many  years  has  been  widely  known  as  a  capa- 


ble teacher  and  trusted  accoucheur,  should  embody 
within  a  single  treatise  the  system  which  he  has 
taught  and  in  practice  tested,  and  which  is  the  out- 
come of  a  lifetime  of  earnest  labor,  careful  obser- 
vation and  deep  study.  Tne  result  of  this  arrange- 
ment is  the  production  oi  a  work  which  rises  above 
criticism  and  which  in  no  respect  need  yield  the 
palm  to  any  obstetrical  treatise  hitherto  published. 
— American  Journal  of  Obstetrics,  Feb.  1886. 


BL  AYE  AIM,  W.  $.,  M.  B.,  F.  R.  C.  B.9 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  New  (fourth) 
American,  from  the  fifth  English  edition.  Edited,  with  additions,  by  Eobert  P.  Har- 
ris, M.  D.  In  one  handsome  octavo  volume  of  654  pages,  with  3  plates  and  201  engrav- 
ings.   Cloth,  $4 ;  leather,  $5 ;  half  Eussia,  $5.50. 

This  still  remains  a  favorite  in  America,  not  supply. — American  Journal  of  Obstetrics,  Nor.  1885. 
only  because  the  author  is  recognized  as  a  safe 
guide  and  eminently  progressive  man,  but  also  as 
sparing  no  effort  to  make  each  successive  edition 
a  faithful  mirror  of  the  latest  and  best  practice. 
A  work  so  frequently  noticed  as  the  present 
requires  no  further  review.  We  believe  that  this 
edition  is  simply  the  forerunner  of  many  others, 
and  that  the  demand  will  keep  pace  with  the 


Since  its  first  publication,  only  eight  years  ago, 
it  has  rapidly  become  the  favorite  text-book,  to 
the  practical  exclusion  of  all  others.  A  large 
measure  of  its  popularity  is  due  to  the  clear  and 
easy  style  in  which  it  is  written.  Few  text-books 
for  students  have  very  much  to  boast  of  in  this 
respect. — Medical  Record. 


KING,  A.  F.  A.,  M.  B., 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 
A  Manual  of  Obstetrics.    New  (third)  edition.    In  one  very  handsome  12mo. 
volume  of  376  pages,  with  102  illustrations.    Cloth,  $2.25.    Just  ready. 


This  little  manual,  certainly  the  best  of  its  kind, 
fully  deserves  the  popularity  which  has  made  a 
third  edition  necessary.  Clear,  practical,  concise, 
its  teachings  are  so  fully  abreast  with  recent  ad- 
vances in  obstetric  science  that  but  few  points 
can  be  criticised. — American  Journal  of  Obstetrics, 
March,  1887. 

This  volume  deserves  commendation.   It  is  not 


bulky — it  is  concise.  The  chapters  are  divided  with 
sub-headings,  which  aid  materially  in  the  finding 
of  any  particular  subject,  and  the  definitions  are 
clear  and  explicit.  It  fulfils  its  purpose  admirably, 
and  we  know  of  no  better  work  to  place  in  the  stu- 
dent's hands.  The  illustrations  are  good. — Arch- 
ives of  Gynecology,  January,  1887. 


BARKER,  FORBTCE,  A.  M.,  M.  B.,  LL.  B.  Edin., 

Clinical  Professor  of '  Midioifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical  College, 
New  York,  Honorary  Fellow  of  the  Obstetrical  Societies  of  London  and  Edinburgh,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.  In  one  handsome  12mo.  volume  of  about 
300  pages.    Preparing.  _  

BARNES,  FANCOURT,  M.  P., 

Obstetric  Physician  to  St.  Thomas'  Hospital,  London. 

A  Manual  of  Midwifery  for  Midwives  and  Medical  Students.  In  one 
royal  12mo.  volume  of  197  pages,  with  50  illustrations.    Cloth,  $1.25. 


BARRY,  JOHN  8.,  M.  B., 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-President  of  the  Obstet.  Society  of  Philadelphia. 
Extra  -  Uterine  Pregnancy:  Its  Clinical  History,  Diagnosis,  Prognosis  and 
Treatment.   In  one  handsome  octavo  volume  of  272  pages.    Cloth,  $2.50. 


TANNER  ON  PREGNANCY.  Octavo,  490  pages,  4  colored  plates,  16  cuts.  Cloth,  $4.25. 


30        Lea  Brothers  &  Co.'s  Publications — Midwfy.,  Dis.  Childn. 


LEISHMAW,  WILLIAM,  M.  !>., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  etc. 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50 ;  very  handsome  half  Russia,  raised  bands,  $6.00. 

The  author  is  broad  in  his  teachings,  and  dis- 
cusses briefly  the  comparative  anatomy  of  the  pel- 
ris  and  the  mobility  of  the  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  study  of  the  pelvis,  while  in  the  third  the 
female   organs   of  generation   are  introduced. 


The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plain  and  pleasing.  It  is  sufficient  to  state  that  in 
this,  the  last  edition  of  this  well-known  work,  every 
recent  advancement  in  this  field  has  been  brought 
forward. — Physician  and  Surgeon,  Jan.  1880. 
To  the  American  student  the  work  before  us 


must  prove  admirably  adapted.  Complete  in  all  its- 
parts,  essentially  modern  in  its  teachings,  and  with 
demonstrations  noted  for  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  as  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended.— N.  O. 
Med.  and  Surg.  Journ.,  March,  1880. 

It  has  been  well  and  carefully  written.  The 
views  of  the  author  are  broad  and  liberal,  and  in- 
dicate a  well-balanced  judgment  and  malurtd 
mind.  "We  observe  no  spirit  of  dogmatism,  but 
the  earnest  teaching  of  the  thoughtful  observer 
and  lover  of  true  science.  Take  the  volume  as  a 
whole,  and  it  has  few  equals. — Maryland  Medical 
Journal,  Feb.  1880. 


LAWDIS,  HEJSTMT  G.,  A.  M.,  M.  !>., 

Professor  of  Obstetrics  and  the  Diseases  of  Women  in  Starling  Medical  College,  Columbus,  O. 

The  Management  of  Labor,  and  of  the  Lying-in  Period.    In  one 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.    Cloth,  $1.75.    Just  ready. 


The  author  has  designed  to  place  in  the  hands 
of  the  young  practitioner  a  book  in  which  he  can 
find  necessary  information  in  an  instant.  As  far 
as  we  can  see,  nothing  is  omitted.  The  advice  is 
sound,  and  the  proceedures  are  safe  and  practical. 
Centralblatt  fur  Gynakulogie,  December  4, 1886. 

This  is  a  book  we  can  heartily  recommend. 
The  author  goes  much  more  practically  into  the 
details  of  the  management  of  labor  than  most 
text-books,  and  is  so  readable  throughout  as  to 


tempt  any  one  who  should  happen  to  commence 
the  book  to  read  it  through.  The  author  pre- 
supposes a  theoretical  knowledge  of  obstetrics., 
and  has  consistently  excluded  from  this  little 
work  everything  that  is  not  of  practical  use  in  the 
lying-in  room.  We  think  that  if  it  i3  as  widely 
read  as  it  deserves,  it  will  do  much  to  improve 
obstetric  practice  in  general. — New  Orleans  Medi- 
cal and  Surgical  Journal,  Mar.  1886. 


SMITH,  J.  LEWIS,  M.  JD., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  Y. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  New  (sixth) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  8G7 
pages,  with  40  illustrations.    Cloth,  $4.50 ;  leather,  $5.50  ;  half  Kussia,  $6.00.    Just  ready. 


Rarely  does  a  pleasanter  task  fall  to  the  lot  of 
the  bibliographer  than  to  announce  the  appearance 
of  a  new  edition  of  a  medical  classic  like  Prof.  J. 
Lewis  Smith's  Treatise  on  the  Diseases  of  Infancy 
and  Childhood.  For  years  it  has  stood  high  in  the 
confidence  of  the  profession,  and  with  the  addi- 
tions and  alterations  now  made  it  may  be  said  to 
be  the  best  book  in  the  language  on  the  subject  of 
which  it  treats.  An  examination  of  the  text  fully 
sustains  the  claims  made  in  the  preface,  that  "in 
preparing  the  sixth  edition  the  author  has  revised 
the  text  to  such  an  extent  that  a  considerable 
part  of  the  book  may  be  considered  new."  If  the 
young  practitioner  proposes  to  place  in  his  library 
but  one  book  on  the  diseases  of  children,  we 
would  unhesitatingly  say,  let  that  book  be  the  one 
which  is  the  subject  of  this  notice.—  The  American 
Journal  of  the  Medical  Sciences,  April,  1886. 

No  better  work  on  children's  diseases  could  be 
placed  in  the  hands  of  the  student,  containing,  as 
it  does,  a  very  complete  account  of  the  symptoms 
and  pathology  of  the  diseases  of  early  life,  and 
possessing  the  further  advantage,  in  which  it 


stands  alone  amongst  other  works  on  its  subject, 
of  recommending  treatment  in  accordance  with 
the  most  recent  therapeutical  views. — British  and 
Foreign  Medico-Chirurgical  Review. 

It  is  a  pleasure  to  the  busy  practitioner — inter- 
ested in  the  advancement  of  his  profession— to 
meet,  fresh  from  the  hands  of  its  author,  a  medi- 
cal classic  such  as  Smith  on  Diseases  of  Children. 
Those  familiar  with  former  editions  of  the  work 
will  readily  recognize  the  painstaking  with  which 
this  revision  has  been  made.  Many  of  the  articles 
have  been  entirely  rewritten.  The  whole  work  is 
enriched  with  a  research  and  reasoning  which 
plainly  show  that  the  author  has  spared  neither 
time  nor  labor  in  bringing  it  to  its  present  ap- 
proach towards  perfection.  The  extended  table  of 
contents  and  the  well-prepared  index  will  enable 
the  busy  practitioner  to  reach  readily  and  quickly 
for  reference  the  various  subjects  treated  of  in  the 
body  of  the  work,  and  even  those  who  are  familiar 
with  former  editions  will  find  the  improvements 
in  the  present  richly  worth  the  cost  of  the  work. — 
Atlanta  Medical  and  Surgical  Journal,  Dec.  1886. 


OWEN,  EDMTJNI},  M.  B.,  F.  It.  C.  S., 

Surgeon  to  the  Children's  Hospital,  Great  Ormond  St.,  London. 


Surgical  Diseases  of  Children. 

chromo-lithographic  plates  and  85  woodcuts. 
ical  Manuals,  page  4. 

One  is  immediately  struck  on  reading  this  book 
with  its  agreeable  style  and  the  evidence  it  every- 
where presents  of  the  practical  familiarity  of  its 
author  with  his  subject.     The  book  may  be 


In  one  12mo.  volume  of  525  pages,  with  4 
Just  ready.    Cloth,  $2.    See  Series  of  Clin- 

honestly  recommended  to  both  students  and 
practitioners.  It  is  full  of  sound  information, 
pleasantly  given.— Annals  of  Surgery,  May,  1886. 


WEST,  CHARLES,  M.  L>., 

,  Physician  to  the  Hospital  for  Sick  Children,  London,  etc. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood. 
12mo.  volume  of  127  pages.    Cloth,  $1.00. 


In  one  small 


WEST'S  LECTURES  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.   In  one  octavo  vol. 
CONDIE'S   PRACTICAL  TREATISE  ON  THE 


DISEASES  OF  CHILDREN.  Sixth  edition,  re- 
vised and  augmented.  In  one  octavo  volume  of 
779  pages.   Cloth,  |5.25 ;  leather,  |6.25. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  Miscel. 


TIDY,  CHABLES  MEYMOTT,  M.  B.,  F.  C.  8., 

Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  etc. 
Legal  Medicine.    Volume  II.    Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Rape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.    Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.    Cloth,  $6.00 ;  leather,  $7.00. 

Volume  I.  Containing  664  imperial  octavo  pages,  with  two  beautiful  colored 
plates.    Cloth,  $6.00 ;  leather,  $7.00. 


The  satisfaction  expressed  with  the  first  portion 
of  this  work  is  in  no  wise  lessened  by  a  perusal  of 
the  second  volume.  We  find  it  characterized  by 
the  same  fulness  of  detail  and  clearness  of  ex- 
pression which  we  had  occasion  so  highly  to  com- 
mend in  our  former  notice,  and  which  render  it  so 
valuable  to  the  medical  jurist.     The  copious 


tables  of  cases  appended  to  each  division  of  the 
subject  must  have  cost  the  author  a  prodigious 
amount  of  labor  and  research,  but  they  constitute 
one  of  the  most  valuable  features  of  the  book, 
especially  for  reference  in  medico-legal  trials. — 
American  Journal  of  the  Medical  Sciences,  April,  1884. 


TAYLOB,  ALFRED  $.,  M.  JD., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital,  London. 

A  Manual  of  Medical  Jurisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edited  by  John  J.  Eeese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00;  leather,  $6.00;  half 
Russia,  raised  bands,  $6.50. 


The  American  editions  of  this  standard  manual 
have  for  a  long  time  laid  claim  to  the  attention  of 
the  profession  in  this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject 
to  which. he  devoted  his  life  with  an  assiduity  and 
success  which  made  him  Jacile  princeps  among 
English  writers  on  medical  jurisprudence.  Both 
the  author  and  the  book  have  made  a  mark  too 
deep  to  be  affected  by  criticism,  whether  it  be 
censure  or  praise.  In  this  case,  however,  we  should 


only  have  to  seek  for  laudatory  terms.— American 
Journal  of  the  Medical  Sciences,  Jan.  1881. 

This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  thirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  is 
simply  indispensable  to  every  physician,  and  nearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26,  1881. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Medical  Jurisprudence.  Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations.  Cloth,  $10 ; 
leather,  $12.    Just  ready. 

For  years  Dr.  Taylor  was  the  highest  authority  matters  connected  with  the  subject,"  should  be 
in  England  upon  the  subject  to  which  he  gave  brought  up  to  the  present  day  and  continued  in 
especial  attention.  His  experience  was  vast,  his  its  authoritative  position.  To  accomplish  this  re- 
Judgment  excellent,  and  his  skill  beyond  cavil.  It  suit  Dr.  Stevenson  has  subjected  it  to  most  careful 
is  therefore  well  that  the  work  of  one  who,  as  Dr.  editing,  bringing  it  well  up  to  the  times. — Ameri- 
Stevenson  says,  had  an  "  enormous  grasp  of  all    can  Journal  of  the  Medical  Sciences,  Jan.  1884. 


By  the  Same  Author. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.  Third 
American,  from  the  third  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.    Cloth,  $5.50 ;  leather,  $6.50. 

JPEPJPEB,  AUGUSTUS  J.,  M.  8.,  M.  B.,  F.  M.  C.  S., 

Examiner  in  Forensic  Medicine  at  the  University  of  Jjondon. 

Forensic  Medicine.  In  one  pocket-size  12mo.  volume.  Preparing.  See  Students? 
Series  of  Manuals,  page  4. 

LEA,  MEN  BY  C. 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revised  and  enlarged  edition.  In  one 
handsome  royal  12mo.  volume  of  552  pages.    Cloth,  $2.50. 


This  valuable  work  is  in  reality  a  history  of  civ 
ilization  as  interpreted  by  the  progress  of  jurispru 
dence.  .  .  In  "  Superstition  and  Force  "  we  have  i 
ophic  survey  of  the  long  P 

civilized  enli 


ic  survey  of  the  long  period  intervening 

d  civilized  enligl 
There  is  not  a  chapter  in  the  work  that 


setween  primitive  barbarity  an 
enment,  " 


ht- 


should  not  be  most  carefully  studied ;  and  however 
well  versed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of  so- 
cial science. —  Westminster  Review,  Jan.  1880. 


By  the  Same  Author. 
Studies  in  Church  History.   The  B-ise  of  the  Temporal  Power- 


-B  cli- 


ent of  Clergy — Excommunication, 
octavo  volume  of  605  pages.    Cloth,  $2.50. 

The  author  is  pre-eminently  a  scholar.  He  takes 
up  every  topic  allied  with  the  leading  theme,  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary.  In  no 
other  single  volume  is  the  development  of  the 


New  edition.  In  one  very  handsome  royal 
Just  ready. 

primitive  church  traced  with  so  much  clearness, 
and  with  so  definite  a  perception  of  complex  or 
conflicting  sources.  The  fifty  pages  on  the  growth 
of  the  papacy,  for  instance,  are  admirable  for  con- 
ciseness and  freedom  from  prejudice. — Boston 
Traveller,  May  3, 1884  - 


Allen's  Anatomy  .... 
American  Journal  of  the  Medical  Sciences 
American  Systems  of  Gynecology  . 
American  System  of  Practical  Medicine . 
Ah  American  System  of  Dentistry 
♦Ashhurst's  Surgery  .... 
Ashwell  on  Diseases  of  Women 
Attfield's  Chemistry  .... 
Ball  on  the  Rectum  and  Anus 
Barker's  Obstetrical  and  Clinical  Essays, 
Barlow's  Practice  of  Medicine 
Barnes'  Midwifery       .        .  . 
*Barnes  on  Diseases  of  Women 
Barnes'  System  of  Obstetric  Medicine 
Bartholow  on  Electricity 
Bartholow's  New  Remedies  and  their  Uses 
Basham  on  Renal  Diseases  . 
Bell's  Comparative  Physiology  and  Anatomy 
Bellamy's  Operative  Surgery 
Bellamy's  Surgical  Anatomy 
Blandford  on  Insanity 
Bloxam's  Chemistry    .  '     .  . 
♦Bristowe's  Practice  of  Medicine  . 
Broadbent  on  the  Pulse 
Browne  on  the  Ophthalmoscope  . 
Browne  on  the  Throat 
Bruce's  Materia  Medica  and  Therapeutics 
Brunton's  Materia  Medica  and  Therapeutics 
Bryant  on  the  Breast  .... 
♦Bryant's  Practice  of  Surgery 
*Bumstead  on  Venereal 
♦Burnett  on  the  Ear  .... 
Butlin  on  the  Tongue  .... 
Carpenter  on  the  Use  and  Abuse  of  Alcohol 
♦Carpenter's  Human  Physiology  . 
Carter  &  Frost's  Ophthalmic  Surgery 
Century  of  American  Medicine 
Chambers  on  Diet  and  Regimen 
Chapman's  Human  Physiology     .  - 
Charles'  Physiological  and  Pathological  Chem. 
Churchill  on  Puerperal  Fever 
Clarke  and  Lockwood's  Dissectors'  Manual 
Classen's  Quantitative  Analysis 
Cleland's  Dissector  .... 
Clouston  on  Insanity  .... 
Clowes'  Practical  Chemistry 
Coats'  Pathology  .... 
Cohen  on  the  Throat  .... 
Coleman's  Dental  Surgery 
Condie  on  Diseases  of  Childre 
Cornil  on  Syphilis  .... 
♦Cornil  and  Ranvier's  Pathological  Histology 
Cullerier's  Atlas  of  Venereal  Diseases 
Curnow's  Medical  Anatomy 
Dalton  on  the  Circulation 
♦Dalton's  HumanPhysiology 
Davis'  Clinical  Lectures 
Draper's  Medical  Physics 
Druitt's  Modern  Surgery 
Duncan  on  Diseases  of  Women      .  . 
♦Dunglison's  Medical  Dictionary  . 
Edes'  Materia  Medica  and  Therapeutics 
Edis  on  Diseases  of  Women  . 
Ellis'  Demonstrations  of  Anatomy 
Emmet's  Gynaecology 
♦Erichsen's  System  of  Surgery 
Esmarch's  Early  Aid  in  Injuries  and  Accld'ts 
Farquharson's  Therapeutics  and  Mat.  Med. 
Fenwick's  Medical  Diagnosis 
Finlayson's  Clinical  Diagnosis 
Flint  on  Auscultation  and  Percussion 
Flint  on  Phthisis  .... 
Flint  on  Physical  Exploration  of  the  Lungs 
Flint  on  Respiratory  Organs 
Flint  on  the  Heart       .        .  ... 
Flint's  Essays  ... 
♦Flint's  Practice  of  Medicine 
Folsom's  Laws  of  U.  S.  on  Custody  of  Insane 
Foster's  Physiology  .... 
♦FothergilFs  Handbook  of  Treatment  . 
Fothergill  on  Mind  and  Liver 
Fownes'  Elementary  Chemistry  . 
Fox  on  Diseases  of  the  Skin  . 
Frankland  and  Japp's  Inorganic  Chemistry 
Fuller  on  the  Lungs  and  Air  Passages  . 
Galloway's  Analysis  .... 
Gibney's  Orthopaedic  Surgery 
GouldTs  Surgical  Diagnosis  . 
♦Gray's  Anatomy  ..... 
Greene's  Medical  Chemistry  .        .  . 
Green's  Pathology  and  Morbid  Anatomy 
Griffith's  Universal  Formulary 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross  on  Impotence  and  Sterility  . 
Gross  on  Urinary  Organs 
♦Gross' System  of  Surgery 
Habershon  on  the  Abdomen 
♦Hamilton  on  Fractures  and  Dislocations 
Hamilton  on  Nervous  Diseases 
Hartshorne's  Anatomy  and  Phypiology  . 
Hartshorne's  Conspectus  of  the  Med.  Sciences 
Hartshorne's  Essentials  of  Medicine 
Hartshorne's  Household  Medicine 
Hermann's  Experimental  Pharmacology 

Hill  on  Syphilis  

Hillier's  Handbook  of  Skin  Diseases 
Hoblyn's  Medical  Dictionary 
Hodge  on  Women  .... 
Hodge's  Obstetrics  .... 
Hoffmann  and  Power's  Chemical  Analysis 
Holden's  Landmarks  .... 


6 

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27 
15 
24 
20 
28 

9 

4,  21 

29 
¥7 

29 
27 
29 
17 
11 
24 


14 
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23 
18 
11 
11 
4,21 
21 
25 
23 
4,21 


4,23 
14 
17 


10 


18 
8 
20 
4,20 
5 
10 
13 
11 
IS 
25 
25 
20 

ie 

22 
19 

6 

3 
14 
17 
11 
25 
26 

4 
28 
28 
10 

5 


Holland's  Medical  Notes  and  Reflections 

♦Holmes' System  of  Surgery 

Horner's  Anatomy  and  Histology  . 

Hudson  on  Fever        .  ... 

Hutchinson  on  Syphilis  . 

Hyde  on  the  Diseases  of  the  Skin  . 

Jones  (C.  Handfield)  on  Nervous  Disorders 

Juler's  Ophthalmic  Science  and  Practice 

King's  Manual  of  Obstetrics  . 

Klein's  Histology  . 

Landis  on  Labor  ..... 

La  Roche  on  Pneumonia,  Malaria,  etc.  . 

La  Roche  on  Yellow  Fever  .... 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye,  Orbit  and  Eyelid 

Lea's  Studies  in  Church  History    .        .  . 

Lea's  Superstition  and  Force 

Lee  on  Syphilis  ... 

Lehmannfs  Chemical  Physiology  . 

♦Leishman's  Midwifery        .        .        .  . 

Lucas  on  Diseases  of  the  Urethra  .  . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever  ...... 

Maisch's  Organic  Materia  Medica  .  . 
Marsh  on  the  Joints 

May  on  Diseases  of  Women  .... 

Medical  News     .  ... 

Medical  News  Visiting  List  .        .        .  . 

Medical  News  Physicians'  Ledger  ... 

Meigs  on  Childbed  Fever  .... 

Miller's  Practice  of  Surgery  .... 

Miller's  Principles  of  Surgery        .  . 

Mitchell's  Nervous  Diseases  of  Women  . 

Morris  on  Diseases  of  the  Kidney  . 

Morris  on  Skin  Diseases  .... 

Neill  and  Smith's  Compendium  of  Med.  Scl.  . 

Nettleship  on  Diseases  of  the  Eye  . 

Norris  and  Oliver  on  the  Eye 

Owen  on  Diseases  of  Children 

♦Parrish's  Practical  Pharmacy 

Parry  on  Extra-Uterine  Pregnancy  . 

Parvin's  Midwifery       .       .       .        .  . 

Pavy  on  Digestion  and  its  Disorders 

Pepper's  System  of  Medicine 

Pepper's  Forensic  Medicine  .... 

Pepper's  Surgical  Pathology 

Pick  on  Fractures  and  Dislocations 

Pirrie's  System  of  Surgery  . 

Playfair  on  Nerve  Prostration  and  Hysteria  . 

♦Playfair's  Midwifery  .  .  . 

Politzer  on  the  Ear  and  its  Diseases 

Power's  Human  Physiology  .... 

Purdy  on  Bright's  Disease  and  Allied  Affections 

Ralfe's  Clinical  Chemistry  - 

Ramsbotham  on  Parturition 

Remsen's  Theoretical  Chemistry  . 

♦Reynolds'  System  of  Medicine  . 

Richardson's  Preventive  Medicine 

Roberts  on  Urinary  Diseases  ... 

Roberts'  Compend  of  Anatomy  . 

Roberts'  Principles  and  Practice  of  Surgery 

Robertson's  Physiological  Physics 

Ross  on  Nervous  Diseases  .... 

Savage  on  Insanity,  including  Hysteria  . 

Schaier's  Essentials  of  Histology, 

Schreiber  on  Massage  .  ... 

Seller  on  the  Throat,  Nose  and  Naso-Pharynx 

Series  of  Clinical  Manuals    .        .        .  . 

Simon's  Manual  of  Chemistry 

Skey's  Operative  Surgery  .... 

Slade  on  Diphtheria  .        .  • 

Smith  (Edward)  on  Consumption  . 

*Smith  (J.  Lewis)  on  Children 

Smith's  Operative  Surgery  . 

Stllle  on  Cholera  ..... 

*Still6  &  Maisch's  National  Dispensatory 

*Still6's  Therapeutics  and  Materia  Medica 

Stimson  on  Fractures  ..... 

Stimson's  Operative  Surgery 

Stokes  on  Fever  .        .        .       .  . 

Students'  Series  of  Manuals  .... 

Sturges'  Clinical  Medicine  .... 

Tanner  on  Signs  and  Diseases  of  Pregnancy 

Tanner's  Manual  of  Clinical  Medicine  . 

Taylor  on  Poisons  ..... 

♦Taylor's  Medical  Jurisprudence  . 

Taylor's  Prin.  and  Prac.  of  Med.  Jurisprudence 

♦Thomas  on  Diseases  of  Women  . 

Thompson  on  Stricture  .... 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine .  .... 

Todd  on  Acute  Diseases        .  '  . 

Treves'  Manual  of  Surgery  .... 

Treves'  Surgical  Applied  Anatomy 

Treves  on  Intestinal  Obstruction  . 

Tuke  on  the  Influence  of  Mind  on  the  Body 

Visiting  List,  The  Medical  News  . 

Walshe  on  the  Heart  ..... 

Watson's  Practice  of  Physic  .       .  . 

♦Wells  on  the  Eye  ..... 

West  on  Diseases  of  Childhood 

West  on  Diseases  of  Women 

West  on  Nervous  Disorders  in  Childhood 

Williams  on  Consumption  .... 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson's  Human  Anatomy  .... 

Winckel  on  Pathol,  and  Treatment  of  Childbed 

Wohler's  Organic  Chemistry         .  . 

Woodhead's  Practical  Pathology  . 

Year-Books  of  Treatment  for  1885  and  1886 


17 
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4 

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26 
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29 
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30 
18 
14 
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23 
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31 
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30 
4,24 
3 
14 
11 
4,22 
28 
1 
3 
3 
28 
20 
20 
19 
4,24 


23 
4,30 
11 
29 
29 
17 
15 
4,31 
4,13 
4,22 
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19 
29 
24 
4,  8 
24 
4,10 
28 
9 
16 
17 
24 
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20 
4,  7 
19 
4,19 
13 
17 
18 
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14 

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17 
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3 
18 
14 
23 
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27 
30 
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26 

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8 
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H 


Books  marked  *  are  also  bound  in  half  Russia. 


ILEA  BROTHERS  &  CO.,  Philadelphia, 


PARRISH'S  PHARMACY.— Fifth  and  Revised  Edition. 


A  Treatise  on  Pharmacy  :  designed  as  a  Text-book  for  the  Student  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and  Prescriptions.  By 
Edward  Parrish,  Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadel- 
phia College  of  Pharmacy.  Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand,  Ph.G. 
In  one  handsome  octavo  volume  of  1093  pages,  with  256  illustrations.  Cloth,  $5.00;  leather,  $6.00. 


There  is  nothing  to  equal  Pavrish's  Pharmaci/  in  this 
or  any  other  language. — London  Pharmaceutical  Jour- 
nal. 

This  classic  work  has  been  too  long  before  the  pro- 
fession to  make  it  necessary  that  it  be  formally  intro- 
duced to  our  readers.  Its  worth  has  been  attested  in 
the  experience  of  a  generation  of  physicians.  For 
the  physician  who  dispenses  his  own  medicines,  and 
is  of  necessity  thus  driven  to  practise  pharmacy  to  a 
certain  extent,  there  is  no  book  to  which  he  will,  in 


his  dual  capacity,  have  occasion  to  refer  so  regularly. 
Its  list  of  formula;  is  peculiarly  rich  in  standard 
preparations.  The  arrangement  of  the  work  is  with  a 
view  to  facilitating  reference  and  avoiding  repetition, 
and  in  this  regard  it  is  a  model. — The  Medical  Age, 
March  25,  1884. 

It  would  be  difficult  to  find  a  more  complete  work, 
for  it  contains  minute  information  upon  every  subject 
pertaining  to  pharmacy. — Cincinnati  Medical  News, 
January,  1884. 


THE  YEAR  BOOK  OF  TREATMENT  FOR  1886. 
A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medicine. 

In  one  12mo.  volume  of  320  pages,  bound  in  limp  cloth,  with  red  edges,  $1.25. 

This  "review"  includes  every  department  of  medi-  whether  he  be  a  general  one  or  a  specialist.  It  is  a 
cal  and  surgical  as  well  as  obstetrical  practice.  It  ;  book  to  be  kept  on  the  office  table  for  continuous 
attempts  nothing  in  the  way  of  etiology,  diagnosis,  ;  reference.  An  excellent  index  to  subjects,  as  well  as 
or  symptoms,  but  limits  itself  to  the  advances  madt!  in  i  to  authors  quoted,  is  appended. —  Virginia  Medical 
the  treatment  of  diseases,  injuries,  etc.  The  work  ;  Monthly,  April,  1887. 
seems  to  us  to  be  invaluable  to  every  practitioner,  ! 

For  special  commutations  with  periodicals  see  last  page  of  cover. 


MITCHELL  ON  THE  NERVOUS  DISEASES  OF  WOMEN. — 
Second  Edition. 

Lectures  on  Diseases  of  the  Nervous  System :  Especially  in  Women. 

By  S.  Weir  Mitchell,  M.D,  Physician  to  the  Orthopaedic  Hospital  and  the  Infirmary  for  Dis- 
eases of  the  Nervous  System,  Philadelphia,  etc.  In  one  12mo.  volume  of  2S8  pages.  Cloth,  $1.75. 

We  feel  sure  that  the  new  edition  of  Dr.  Mitchell's  I  terests  every  practitioner,  and  his  views  on  treatment 
admirable  lectures  will  be  received  on  this  side  of  the  |  are  gradually  receiving  general  acceptance. — London 
Atlantic  with  more  than  ordinary  attention.  His  sub-  I  Medical  Times  and  Gazette,  July  4,  1885 
ject,  the  nervous  disorders  of  women,  is  one  that  in-  | 


TUKE  ON  THE  INFLUENCE  OF  THE  MIND  UPON  THE  BODY 
IN  HEALTH  AND  DISEASE.— Second  Edition. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 

and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  By  Daniel  Hack  Tuke, 
M.D.,  Joint  Author  of  the  Manual  of  Psychological  Medicine,  etc.  Second  edition,  thoroughly 
revised  and  rewritten.    In  one  8vo.  volume  of  467  p^ges,  with  2  colored  plates.    Cloth,  $3.00. 

The  subject  of  the  various  and  potent  influences  of  I  if  he  is  intelligent,  will  not  see,  and  if  wise,  utilize 
the  imagination  upon  bodily  function  is  one  concern- I  psychical  therapeutics.  It  is  a  dens  major  in  his 
ing  which  every  physician  should  be  thoroughly  cog-  I  armamentarium. — Medical  Record,  February,  21, 1885. 
nizant.    There  is  not  a  practitioner  of  medicine  who,  | 


TAYLOR'S  MEDICAL  JURISPRUDENCE  — Tenth  Edition. 
A  Manual  of  Medical  Jurisprudence    By  Alfred  S.  Taylor.  M.D.,  Lec- 

turer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital,  London.  Eighth  American 
from  the  tenth  London  edition,  thoroughly  revised  and  rewritten.  Edited  by  Johv  J.  Rbrse, 
M.D.,  Professor  of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania. 
In  one  large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00,  leather,  $6.00  ; 
half  Russia,  raised  bands,  $6.50. 

In  all  our  American  courts  of  justice,  when  an  an-  I  courts,  juries  and  professional  mon— perhaps  no  one 
thority  is  sought  for  in  jurisprudence,  the  name  of  |  standing  so  high  —Pacific  Medical  and  Su rgical  Jour- 
Taylor  is  first  presented     There  is  no  other  author  I  nal,  January,  1881. 
on  the  subject  whose  name  carries  greater  weight  with  | 


Full  descriptive  catalogue  will  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  &  CO..  Publishers,  Philadelphia. 


PEOSPECTUS  FOE  1887. 


The  American  Journal  of  the  Medical  Sciences. 

Five  Dollars  per  Annum. 

Published  quarterly,  on  the  first  of  January,  April,  July  and  October.    Each  number 
contains  from  300  to  350  large  octavo  -pages  fully  illustrated. 

Readers  of  The  Journal  will  recollect  that,  with  the  January  issue  of  1886,  this 
periodical  became  the  recognized  organ  of  the  profession  in  Great  Britain,  assuming  a 
position  similar  to  that  conceded  to  it  in  this  country  for  the  past  sixty-six  years.  A 
glance  at  the  details  of  this  new  departure,  which  are  published  on  page  8  of  the 
advertising  sheet  at  the  beginning  of  this  number,  will  show  that  The  Journal  has 
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globe.  A  feature  of  The  News  during  1887  will  be  the  appearance  at  frequent  inter- 
vals of  a  special  series  of  practical  articles,  showing  the  methods  of  treating  various 
prevalent  diseases  adopted  in  the  principal  hospitals  of  this  country.  The-e  concise 
and  authoritative  notes  on  practice  must  obviously  prove  of  the  greatest  clinical  value 
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early  notes  of  all  important  advances,  gleaned  from  the  principal  journals  of  both 
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intelligence  bearing  on  all  departments  of  medical  science. 

THE  YEAR  BOOK  OF  TREATMENT  FOR  1886. 

Duodecimo,  320  Pages.    Cloth,  $1.25. 

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LEA  BROTHERS  &  CO.,  Nos.  706  and  708  Sansom  Street,  Philadelphia. 


No.  188-.^New  Series. 


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THE 


AMERICAN  JOURNAL 


MEDICAL  SCIENCES. 

(the  international  journal  of  the  medical  sciences.) 
Published  Simultaneously  in  Philadelphia  and  London. 


P 

P 


EDITED  BY 


I.  MINIS  HAYS,  A.M.,  M.D., 


PHILADELPHIA, 


AND 


MALCOLM  MORRIS,  M.R.C.S., 

LONDON. 


PHILADELPHIA: 

LEA  BROTHERS  &  CO. 

LONDON: 

CASSELL  &  COMPANY,  Limited. 
1887. 


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ANNOUNCEMENTS. 


GRAY'S  ANATOMY.— New  (Eleventh)  Edition.    Just  Ready. 

IN  COLORS  OR  IN  BLACK. 

Anatomy,  Descriptive  and  Surgical.  By  Henry  Gray,  F.K.S.,  Lec- 
turer on  Anatomy  at  St.  George's  Hospital,  London.  Edited  by  T.  Pickering  Pick,  F.R.C.S., 
Surgeon  to  and  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London  ;  Examiner  in  Anatomy, 
Royal  College  of  Surgeons  of  England.  A  new  American,  from  the  eleventh  enlarged  and 
improved  London  edition,  thoroughly  revised  and  re-edited  by  William  W.  Keen,  M.D., 
Professor  of  Anatomy  in  the  Pennsylvania  Academy  of  the  Fine  Arts,  etc.  To  which  is  added 
the  second  American,  from  the  latest  English  edition  of  Landmarks,  Medical  and  Surgical,  by 
Luther  Holden,  F.R.C.S.  In  one  imperial  octavo  volume  of  1139  pages,  with  about  650  large 
and  elaborate  engravings  on  wood.  Price  of  edition  in  black;  Cloth,  $6.00;  leather,  $7.00 ; 
half  Russia,  $7.50.    The  price  of  edition  in  colors  will  be  announced  shortly. 


CHAPMAN'S  HUMAN  PHYSIOLOGY".— In  a  few  days. 
A  Treatise  on  Human  Physiology.    By  Henry  C.  Chapman,  M.D., 

Professor  of  the  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical 
College  of  Philadelphia.  In  one  handsome  octavo  volume  of  about  900  pages,  profusely 
illustrated. 


EDBS'  MATERIA  MEDICA  AND  THERAPEUTICS. — In  a  few  days. 
A  Text-Book  of  Materia  Medica  and  Therapeutics.    By  Kobert  T. 

Edes,  M.D.,  Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Depart- 
ment.   In  one  octavo  volume  of  about  600  pages. 


DRUITT'S  MODERN  SURGERY.— New  (Twelfth)  Edition.  Just  Ready. 

Manual  of  Modern  Surgery.    By  Kobert  Drtjitt,  M.K.C.S.,  etc.  Twelfth 

edition,  thoroughly  revised  by  Stanley  Boyd,  M.B.,  B.S.,  F.R.C.S.  In  one  octavo  volume  of 
965  pages,  with  373  illustrations.    Cloth,  $4.00;  leather,  $5.00 


MAISCH'S  MATERIA  MEDICA.— New  Edition.    Very  Shortly. 

A  Manual  of  Organic  Materia  Medica :    Being  a  Guide  to  Materia 

Medica  of  the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Phar- 
macists, and  Physicians.  By  John  M.  Maisch,  Pbar.D.,  Professor  of  Materia  Medica  and 
Botany  in  the  Philadelphia  College  of  Pharmacy.  Third  edition.  In  one  handsome  royal 
12mo.  volume  of  about  550  pages,  with  about  250  illustrations. 


REMSEN'S  THEORETICAL  CHEMISTRY  —New  Edition.  Just  Ready. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Con- 
stitution of  Chemical  Compounds.  By  Ira  Remsen,  M.D.,  Ph.D.,  Professor  of  Chemistry  in 
the  Johns  Hopkins  University,  Baltimore.  New  (third)  and  revised  edition.  In  one  handsome 
royal  12mo.  volume  of  about  350  pages. 


HUTCHINSON  ON  SYPHILIS. — Just  Ready. 

Syphilis.  By  Jonathan  Hutchinson,  LL.D.,  F.K.S.,  F.K.C.S.,  Consulting 
Surgeon  to  the  London  Hospital.  In  one  12mo  volume  of  542  pages,  with  8  chromo  lithographs. 
Cloth,  $2.25.    Series  of  Clinical  Manuals. 


COHEN  ON  THE  THROAT  AND  NOSE— New  Edition.  Preparing. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diag- 
nosis and  Treatment  of  Affections  of  the  Pharynx,  GEsophagus,  Trachea,  Larynx  and  Nares. 
By  J.  Solis-Cohen,  M.D.,  Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in 
the  Jefferson  Medical  College  of  Philadelphia.  Third  edition,  thoroughly  revised  and  rewritten, 
with  a  large  number  of  new  illustrations.    In  one  very  handsome  octavo  volume. 


STIMSON  ON  DISLOCATIONS— In  Press. 
A  Practical  Treatise  on  Fractures  and  Dislocations.    By  Lewis  A. 

Stimson,  B.A.,  M.D.,  Professor  of  Pathological  Anatomy. at  the  University  of  the  City  of  New 
York;  Surgeon  and  Curator  to  Bellevue  Hospital;  Surgeon  to  the  Presbyterian  Hospital,  New 
York,  etc.    Vol.  II.,  Dislocations.    Handsome  octavo  of  500  pages,  with  about  200  illustrations. 


XtizFFull  detailed  catalogue  will  be  found  at  the  end  of  this  volume. 


LEA  BROTHERS  &  CO.,  Publishers,  Philadelphia. 


Prospectus  for  1888. 


THE  MONTHLY  PUBLICATION  OF 
THE 

American  Journal  of  the  Medical  Sciences. 

To  be  issued  each  month,  beginning  with  January,  1888.    Over  100  large  octavo 
pages  of  reading  matter  in  each  number. 

Subscription  Price  Reduced  to  $4.00  per  annum. 

THE  large  circle  of  readers  of  The  American  Journal  of  the  Medical 
Sciences  will  learn  with  satisfaction  that,  with  the  coming  of  the  New- 
Year,  they  will  receive  its  visits  monthly  instead  of  quarterly,  as  heretofore. 
This  change  is  simply  a  further  development  of  that  spirit  which  has  caused 
The  Journal,  during  two  generations,  to  be  always  the  leader  in  medical 
thought,  divining  the  needs  of  the  profession,  and  shaping  itself  for  their  ade- 
quate supply.  The  period  thus  far  spanned  by  the  life  of  The  Journal  is, 
par  excellence,  the  Augustan  Age  of  medicine.  Never  before  in  history  have 
the  brains  of  individual  men  been  so  heavily  taxed,  or  so  fertile  in  physical 
benefit  to  the  human  race.  If  the  present  rate  of  progress  is  to  be  accelerated 
or  even  maintained,  it  can  only  be  by  means  of  increased  rapidity  in  the 
interchange  of  thought,  and  by  a  still  greater  condensation  in  bringing  to  the 
reader  the  results  of  the  daily  accumulating  contributions  to  our  knowledge 
of  disease  and  its  prevention  or  its  remedies.  To  accomplish  this  end  The 
Journal  of  the  future  here  devotes  itself.  Its  position  for  the  last  sixty-eight 
years  as  the  authoritative  organ  of  the  most  advanced  minds  of  the  profes- 
sion offers  the  surest  guarantee  of  its  future  usefulness  under  its  enlarged 
opportunities. 

Those  friends  who  have  become  attached  to  the  present  form  of  The 
Journal  will  be  gratified  to  learn  that  no  change  in  its  shape  and  appearance 
has  been  deemed  advisable.  Its  total  yearly  size  will  be  somewhat  increased, 
while  its  individual  parts  will  be  smaller  and  more  convenient  for  mental 
and  physical  grasp.  A  larger  proportion  of  space  will  be  devoted  to  Original 
Articles,  which  will  be  on  an  average  shorter  than  at  present,  so  that  every 
reader  may  not  fail  to  find  in  each  number  something  of  direct  interest  to 
himself.  The  Department  of  Progress  will  continue  to  furnish  an  able  and 
systematized  epitome  of  the  world's  medical  advance  under  the  headings  of 
Anatomy;  Physiology;  Materia  Medica,  Therapeutics,  and  Pharmacology; 
Medicine;  Surgery;  Ophthalmology;  Otology;  Laryngology;  Dermatology  : 
Midwifery  and  Gynecology;  Medical  Jurisprudence  and  Toxicology,  and 
Public  Health,  in  charge  of  specialists  whose  respective  positions  are  a  .-u in- 
dent earnest  that,  while  nothing  of  interest  is  omitted,  equal  care  is  exercised 
that  no  opinion  is  advanced  that  is  not  worthy  of  the  complete  confidence  of 
all  practitioners. 

To  accommodate  the  increase  in  these  two  divisions  The  JOURNAL  will  be 
somewhat  enlarged,  and  the  Department  of  Reviews  will  be  condensed,  ye1 

The  Medical  News  and  The  Medical  News  Visiting  List  -See  next 
page  and  also  last  page  of  Cover. 


The  American  Journal  of  the  Medical  Sciences,  as  a  Monthly— Continued. 


without  sacrifice  of  the  pithiness  and  candor  which  have  marked  its  literary 
judgments  in  the  past. 

Subscription  Rate  reduced  to  $4.00  per  annum. 

Basing  their  estimates  upon  the  greatly  enhanced  practical  value  of  a 
monthly  as  compared  with  a  quarterly,  the  publishers  have  decided  that  their 
subscribers  shall  have  the  advantage  of  the  decrease  in  cost  per  copy  effected 
by  the  increased  number  to  be  printed.  It  is  safe  to  say  that  in  no  other 
publication  of  its  kind  can  an  investment  be  made  with  the  certainty 
of  so  rich  a  return.  When  taken  in  connection  with  the  weekly  Medical 
News,  the  reader  can  rest  assured  that  nothing  of  importance  in  the  life  of 
the  great  medical  world  will  escape  his  attention.  To  lead  every  subscriber 
to  prove  this  fact  for  himself,  the  Commutation  Rate  has  been  greatly  re- 
duced, being  fixed  at  the  exceedingly  low  figure  of  Seven  Dollars  and  Fifty 
Cents  per  annum  in  advance. 


THE  MEDICAL  NEWS— WEEKLY. 

28-32  Quarto  Pages  of  Heading  Matter.   $5.00  per  annum. 

Founded  as  a  monthly  in  1843,  The  Medical  News  assumed  a  weekly 
form  in  1882,  thereby  inaugurating  a  marked  and  permanent  change  in 
American  medical  journalism.  It  undertook  to  supply  a  medical  magazine 
and  newspaper  in  the  largest  and  highest  sense  of  both  terms,  and  to  this  end 
its  energies  have  been  devoted  with  unflagging  assiduity.  Presenting  a  con- 
veniently large  amount  of  well-digested  matter  each  week,  it  enables  the 
general  practitioner  to  keep  advised  of  the  thought,  experience,  and  discoveries 
of  his  colleagues  in  all  parts  of  the  world  at  a  minimum  expense  of  time  and 
money.  Posted  by  its  crisp  journalism,  and  completing  his  knowledge  with 
the  more  elaborate  pages  of  the  Monthly  American  Journal,  the  reader 
may  feel  secure  that  nothing  of  importance  can  escape  him.  To  aid  in  ex- 
tending the  advantages  of  this  combination  the  publishers  have  decided  to 
reduce  the  Commutation  Rate  for  the  two  periodicals  to  $7.50  per  annum  in 
advance. 

TERMS  OF  SUBSCRIPTION  AND  COMMUTATION  RATE. 

The  Medical  News,  Weekly  ($5.00  per  annum.)  \  Together  to  one  address, 
The  American  Journal  of  the  Medical  Sciences,  y    by  mail  $7  50  per  an- 

Monthly.     ($4.00    per    annum.)     See    preceding        num,  in'advance. 

page.  ) 

*^  Specimen  copies  of  either  of  these  periodicals  will  be  sent,  free  of 
cost,  on  application  to  the  publishers. 


THE  MEDICAL  NEWS  VISITING  LIST,  1888. 

Upon  its  first  issue  in  1885  The  Medical  News  Visiting  List  was  recog- 
nized as  the  most  convenient  and  handsome  pocket  record  book  attainable, 
and  it  is  steadily  growing  in  favor  as  its  merits  become  known.  It  contains 
48  pages  of  useful  data,  and  176  pages  of  ruled  blanks  subdivided 
under  various  appropriate  heads,  and  is  furnished  with  a  pocket  pencil, 
erasable  tablet,  and  catheter  scale,  all  being  brought  within  a  size  suitable 
for  carriage  about  the  person.  It  will  be  issued  in  three  styles  : — Weekly, 
for  30  patients  ;  Monthly,  and  Perpetual.  Price,  each,  $1.25.  For  further 
details,  including  Special  Offers,  see  last  page  of  cover. 

The  American  Journal  of  the  Medical  Sciences  as  a  Monthly,  $4  per  annum. 
See  Announcement  on  preceding  page. 


JfleMcal  cmb  Surgical  <£e*t  cmfr  Beference  Books. 

FLINT'S  PRINCIPLES  AND  PRACTICE  OF  MEDICINE. 
Sixth  Edition. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.    Designed  for 

the  Use  of  Students  and  Practitioners  of  Medicine.  By  Austin  Flint,  M.D.,  LL.D.,  Professor 
of  the  Principles  and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  Bellevue  Hospital 
Medical  College,  New  York.  New  (sixth)  edition,  thoroughly  revised  and  rewritten  by  the 
author,  assisted  by  William  H.  Welch,  M.D.,  Professor  of  Pathology  Johns  Hopkins  Uni- 
versity, Baltimore,  and  Austin  Flint,  Jr.,  M.D.,  LL.D.,  Professor  of  Physiology,  Bellevue 
Hospital  Medical  College,  New  York.  In  one  very  handsome  octavo  volume  of  1170  pages, 
with  illustrations.  Cloth,  $5.50;  leather,  $6.50 ;  very  handsome  half  Russia,  raised  bands, 
$7.00. 

No  text-book  on  the  principles  and  practice  of  medi-  i  will  be  most  likely  to  be  found  in  the  office  of  a  medi- 
cine has  ever  met  in  this  country  with  such  general  |  cal  man,  whether  in  city,  town,  village,  or  at  some 
approval  by  medical  students  and  practitioners  as  the  j  cross-roads,  is  Flint's  Practice.  The  work  may  un- 
work  of  Professor  Flint.  In  all  the  medical  colleges  doubtedly  be  regarded  as  fairly  representing  the  pre- 
of  the  United  States  it  is  the  favorite  work  upon  Prac-   sent  state  of  the  science  of  medicine,  and  as  reflecting 


tice  ;  and,  as  we  have  stated  before  in  alluding  to  it, 
there  is  no  other  medical  work  that  can  be  so  gener- 
ally found  in  the  libraries  of  physicians.  In  every 
State  and  Territory  of  this  vast  country  the  book  that 


the  views  of  those  who  exemplify  in  their  practice  th( 
present  stage  of  progress  of  medical  art. — Cincinnati 
Medical  News,  October,  1886. 


STILLE  AND  MAISCH'S  NATIONAL  DISPENSATORY. — 
Fourth  Edition. 

The  National  Dispensatory  :  Containing  the  Natural  History,  Chemistry, 
Pharmacy,  Actions,  and  Uses  of  Medicines,  including  those  recognized  in  the  Pharmacopoeias 
of  the  United  States,  Great  Britain  and  Germany,  with  numerous  references  to  the  French 
Codex.  By  Alfred  Stille,  M.D.,  LL.D.,  Professor  Emeritus  of  the  Theory  and  Practice  of 
Medicine  and  of  Clinical  Medicine  in  the  University  of  Pennsylvania,  and  John  M.  Maisch, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy, 
Secretary  to  the  American  Pharmaceutical  Association.  Fourth  edition,  revised  and  covering 
the  new  British  Pharmacopoeia.  In  one  magnificent  imperial  octavo  volume  of  1794  pages,  with 
311  elaborate  engravings.  Price  in  cloth,  $7. 25  ;  leather,  raised  bands,  $8. 00  ;  very  handsome 
half  Russia,  raised  bands  and  open  back,  $9.00. 

This  work  will  be  furnished  with  Patent  Beady  Reference  Thumb-letter  Index  for  81 
in  addition  to  the  price  in  any  style  of  binding. 

We  think  it  a  matter  for  congratulation  that  the  the  pharmaceutist  can  do  without  the  latest  text-books 

profession  of  medicine  and  that  of  pharmacy  have  on  them,  especially  those  that  are  so  accurate  and 

shown  such  appreciation  of  this  great  work  as  to  call  comprehensive  as  this  one.     The  book  is  in  every 

for  four  editions  within  the  comparatively  brief  period  way  creditable,  both  to  the  authors  and  to  the  pub- 

of  eight  years.    The  matters  with  which  it  deals  are  lishers. — New  York  Medical  Journal,  May  21,  1887. 
of  so  practical  a  nature  that  neither  the  physician  nor 


D ALTON'S  PHYSIOLOGY.— Seventh  Edition. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  By  John  C.  Dalton,  M.D.,  Professor  of  Physiology  in  the  College 
of  Physicians  and  Surgeons,  New  York,  etc.  Seventh  edition,  thoroughly  revised  and  re- 
written. In  one  very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on 
wood.    Cloth,  $5;  leather,  $6  ;  very  handsome  half  Russia,  raised  bands,  $6.50. 

The  merits  of  Prof.  Dalton's  text-book,  his  smooth  I  par  excellence;  from  it  they  get  their  rudiments  in  such 
and  pleasing  style,  the  remarkable  clearness  of  his  I  a  way  as  they  can  get  them  nowhere  else.  If  asked 
descriptions,  which  leave  not  a  chapter  obscure,  his  which  one  book  to  get  on  physiology,  the  answer,  with- 
cautious  judgment  and  the  general  correctness  of  his  |  out  hesitation,  would  be,  Dalton. —  Cincinnati  Lancet 
facts,  are  perfectly  known.  They  have  made  his  text-  I  and  Clinic,  March  11,  1882. 

book  the  one  most  familiar  to  American  students. —  One  can  scarcely  open  a  college  catalogue  that  does 
Medical  Record,  March  4,  1882.  I  not  have  mention  of  Dalton's  Physiology  as  the  recom- 

We  hail  this  new  edition  of  our  old  favorite  with  i  mended  text-  or  consultation-book.     For  American 
pleasure.    He  is  abreast  of  his  many  competitors,  as  j  students  we  would  unreservedly  recommend  Dr.  Dal- 
is  shown  by  the  many  additions  made  in  this  last  j  ton's  work. — Virginia  Medical  Monthly,  July,  1SS2. 
edition.    This  is  the  text-book  for  students,  the  work  [ 

ATTFIELD'S  CHEMISTRY.— Tenth  Edition. 
Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the 

Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science,  and 
their  Application  to  Medicine  and  Pharmacy.  By  John  Attfiei.d,  Ph.D.,  Professor  of  Prac- 
tical Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  etc.  A  new  American,  from 
the  tenth  English  edition,  specially  revised  by  the  author.  In  one  handsome  roval  12mo. 
volume  of  728  pages,  with  S7  illustrations.    Cloth,  $2.50  ;  leather,  $3.00. 

COATS'  PATHOLOGY. 

A  Treatise  on  Pathology.  By  Joseph  Coats,  M.D.,  F.F.P.S.,  Pathologist 
to  the  Glasgow  Western  Infirmary.  In  one  very  handsome  octavo  volume  of  829  pages,  with 
339  beautiful  illustrations.    Cloth,  $5.50  ;  leather,  $0.50. 


Full  descriptive  catalogue  will  be  found  at  the  end  of  this  volume. 

LEA  BROTHERS  &  CO.,  PUBLISHERS,  PHILADELPHIA. 


Jtlebkal  cmft  Surgical  &zxt  anh  Reference  Books. 


PARVIN'S  OBSTETRICS. — Just  Ready. 
The  Science  and  Art  of  Obstetrics.    By  Theophilus  Parvin,  M.D., 

LL.D.,  Professor  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  the  Jefferson 

Medical  College  of  Philadelphia.    In  one  very  handsome  octavo  volume  of  697  pages,  with  214 

illustrations  and  a  colored  plate.    Cloth,  $4.25;  leather,  $5.25. 

It  is  a  ripe  harvest  that  Dr.  Parvin  offers  to  his  '  This  treatise  may  be  defined  as  exact,  concise  and 
readers.  There  is  no  book  that  can  be  more  safely  !  scholarly.  Parvin's  distinguished  position  as  a  teacher, 
recommended  to  the  student,  or  that  can  be  turned  to  j  his  scholarly  attainments,  and  his  honest  endeavor  to 
in  moments  of  doubt  with  with  greater  assurance  of  ;  do  his  best  by  both  the  student  and  the  physician, 
aid,  as  it  is  a  liberal  digest  of  safe  counsel  that  has  i  will  secure  for  his  treatise  favorable  recognition. — 
been  patiently  gathered. — The  American  Journal  of  the  American  Journal  of  Obstetrics,  May,  1887. 
Medical  Sciences,  July,  1887.  I 

SMITH'S  OPERATIVE  SURGERY. — New  Edition. 
The  Principles  and  Practice  of  Operative  Surgery.    By  Stephen 

Smith,  M.D.,  Professor  of  Clinical  Surgery  in  the  University  of  the  City  of  New  York.  New 
(second)  and  thoroughly  revised  edition.  In  one  very  handsome  octavo  volume  of  892  pages, 
with  1005  illustrations.    Cloth,  $4.00;  leather,  $5.00. 

Prof.  Smith's  Operative  Surgery  may  be  termed  a  [  in  such  a  lucid  manner  that  it  may  be  mastered  and 
model  text-book  in  every  respect.  This,  the  second  utilized  by  every  practitioner.  The  mere  announce- 
edition  of  this  well-known  work  appears  thoroughly  ment  of  the  appearance  of  the  work  in  the  second 
revised,  and  considerably  enlarged.  It  may  be  said  |  edition  is  all  that  is  necessary,  for  everyone  unites  in 
to  comprise  all  the  many  and  most  important  changes  j  regarding  it  as  decidedly  the  best  work  upon  opera- 
that  have  been  made  within  the  past  few  years  in  sur-  tive  surgery  extant. — Nashville  Journal  of  Medicine  and 
gical  manipulations.  The  most  careful  attention  has  Surgery,  April,  1887. 
been  given  to  the  exposition  of  antiseptic  surgery,  and  | 

NETTLESHIP  ON  THE  EYE. — New  Edition.    Just  Ready. 
The  Student's  Guide  to  Diseases  of  the  Eye.   By  Edward  Nettleship, 

F.R.C.S.,  Ophthalmic  Surgeon  and  Lecturer  on  Ophthalmic  Surgery  at  St.  Thomas'  Hospital, 
London.  New  third  American  from  the  fourth  English  edition,  thoroughly  revised.  With  a 
chapter  on  the  Detection  of  Color-Blindness,  by  William  Thomson,  M.D.,  Ophthalmologist  to 
the  Jefferson  Medical  College.  In  one  royal  12mo.  volume  of  479  pages,  with  164  woodcuts* 
test-type  and  formulas.    Cloth,  $2.00. 

Four  English  and  three  American  editions  published  within  eight  years,  attest  the  value 
of  this  work  not  only  to  students  but  also  to  practitioners.  It  is  safe  to  say  that  the  profession 
has  at  its  command  no  other  brief  work  which  gives  so  thorough  and  satisfactory  an  exposition 
of  the  whole  subject  of  ophthalmology,  including  the  principles  of  optics,  the  use  of  instruments 
for  examination,  the  methods  of  prescribing  glasses,  and  the  medical  and  surgical  treatment  of 
the  various  diseases  of  the  eye. 

EMMET'S  GYNECOLOGY.— Third  Edition. 
The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students 

and  Practitioners  of  Medicine.  By  Thomas  Addis  Emmet,  M.D.,  LL.D.,  Surgeon  to  the  Woman's 
Hospital,  New  York,  etc.  Third  edition,  thoroughly  revised.  In  one  large  and  very  handsome 
octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  $5.00;  leather,  $6.00;  half  Bussia, 
raised  bands,  $6.50. 

Medical  students  and  physicians  will  find  no  work  valuable,  practical  knowledge  set  forth  in  a  clear, 
that  better  elucidates  the  etiology,  pathology  and  interesting  style. — Cincinnati  Medical  Neics,  January, 
treatment  of  diseases  of  women.    It  is  a  treasury  of  1885. 


ERICHSEN'S  SURGERY. — Eighth  Edition. 

The  Science  and  Art  of  Surgery;  Being  a  Treatise  on  Surgical  Injuries, 

Diseases  and  Operations.    By  John  E.  Erichsen,  E.B.S.,  F.B.C.S.,  Professor  of  Surgery  in 

University  College,  London,  etc.     From  the  eighth  and  enlarged  English  edition.     In  two 

large  and  beautiful  octavo  volumes  of  2316  pages,  illustrated  with  984  engravings  on  wood. 

Cloth,  $9.00;  leather,  raised  bands,  $11.00;  half  Kussia,  raised  bands,  $12.00. 

For  many  years  this  classic  work  has  been  made  by  I  world.  No  discovery,  device,  or  improvement  which 
the  preference  of  teachers  the  principal  text-book  in  '  has  marked  the  progress  of  surgery  during  the  last 
surgery  for  medical  students,  while  through  transla-  decade  has  been  omitted.  The  illustrations  are  many 
tion  into  the  leading  continental  languages  it  may  be  :  and  executed  in  the  highest  style  of  art. — Louisville 
said  to  guide  the  surgical  teaching  of  the  civilized  j  Medical  News,  Feb.  14,  1885. 


J%jf  Full  descriptive  catalogue  will  be  found  at  the  end  of  this  volume. 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES. 

OCTOBER,  1  887. 


CONTRIBUTORS  TO   THIS  VOLUME. 


KOBERTS  BARTHOLOW,  M.D.,  Professor  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson 

Medical  College,  Philadelphia. 
EDWARD  N.  BRUSH,  M.D.,  Assistant  Physician  to  the  Pennsylvania  Hospital  for  the  Insane. 
CHARLES  H.  BURNETT,  M.D.,  Professor  of  Otology  in  the  Philadelphia  Polyclinic. 

SWAN  M.  BURNETT,  M.D.,  Director  of  the  Ophthalmological  and  Otological  Clinic,  Central  Dispensary t 

Washington. 

W.  WATSON  CHEYNE,  M.D.,  Assistant  Surgeon  to  King's  College  Hospital,  London. 

J.  MITCHELL  CLARKE,  M.D.,  Assistant  Physician  to  the  Bristol  General  Hospital,  England. 

J.  SOLIS-COHEN,  M.D.,  Prof essor  of  Diseases  of  the  Throat  and  Chest,  Philadelphia  Polyclinic. 

B.  FARQUHAR  CURTIS,  M.D.,  Assistant  Surgeon  to  the  New  York  Cancer  Hospital. 
LOUIS  A.  DLTHRING,  M.D.,  Professor  of  Dermatology  in  the  University  of  Pennsylvania. 
CHARLES  W.  DULLES,  M.D.,  Surgeon  to  Outpatients  in  Hospital  of  University  of  Pennsylvania. 
HAROLD  C.  ERNST,  M.D.  Haet.,  Demonstrates  of  Bacteriology  in  the  Medical  School  of  Harvard  Univ. 
L.  WEBSTER  FOX,  M.D.,  Ophthalmic  Surgeon  to  the  Germantown  Hospital,  Philadelphia. 

THOMAS  R.  FRASER,  M.D.,  Prof  essor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  University  of 
Edinburgh. 

WILLIAM  C.  GLASGOW.  M.D.,  Professor  of  Diseases  of  the  Chest  and  Throat  in  the  St.  Louis  Post- 

Graduate  School  of  Medicine. 
J.  P.  CROZER  GRIFFITH,  M.D.,  Assistant  to  the  Professor  of  Clinical  Medicine  in  the  University  of 

Pennsylvania. 

SAMUEL  W.  GROSS,  M.D.,  Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery  in  the  Jefferson 

Medical  College  of  Philadelphia. 
WILLIAM  S.  HALSTED,  M.D.,  of  New  York. 

HOBART  A.  HARE,  M.D.,  Demonstrator  of  Experimental  Therapeutics  in  the  University  of  Pennsylvania. 
ROBERT  P.  HARRIS,  M.D.,  of  Philadelphia. 

D.  BERRY  HART,  M.D  ,  Lecturer  on  Midwifery  and  Diseases  of  Women,  Surgeon's  Hall,  Edinburgh,  etc. 
MATTHEW  HAY,  M.D.,  Professor  of  Medical  Jurisprudence,  University  of  Aberdeen. 

R.  PALMER  HOWARD,  M.D.,  Professor  of  Medicine  in  McGill  University,  Montreal. 
EDWARD  JACKSON,  M.D.,  Adjunct  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic. 
F.  P.  KINNICUTT,  M.D.,  Physician  to  St.  Luke's  Hospital,  New  York. 
ROBERT  W.  LOVETT,  M.D.,  of  Boston. 

J.  A.  MACDOUGALL,  M.D.,  Consulting  Surgeon  to  the  Cumberland  Infirmary,  etc.,  England. 
WILLIAM  MACEWEN,  Surgeon,  and  Lecturer  on  Surgery,  to  Royal  Infirmary,  Glasgow. 
WALTER  MENDELSON,  M.D.,  Instructor  in  the  Laboratory  of  the  College  of  Physicians  and  Suryeuas, 
New  York. 

GEORGE  S.  MIDDLETON,  M.D.,  Assistant  Physician  to  the  Royal  Infirmary,  Glasgow. 

S.  WEIR  MITCHELL,  M.D.,  Physician  to  the  Infirmary  for  Nervous  Diseases,  Philadelphia. 

JOHN  C.  MUNRO,  M.D.,  of  Boston. 

SHIRLEY  F.  MURPHY,  M.R  C.S.,  Lecturer  on  Hygiene  and  Public  Health,  St.  Mary's  Hospital,  London. 

C.  B.  NANCREDE,  M.D.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 
WILLIAM  OSLER,  M.D.,  Prof  essor  of  Clinical  Medicine  in  the  University  of  Pennsylvania. 
THEOPHILUS  PARVIN,  M.D.,  Professor  of  Obstetrics  in  Jefferson  Medical  College,  Philadelphia. 

T.  G.  RICHARDSON,  M.D.,  Professor  of  General  and  Clinical  Surgery,  Tulane  University,  New  Orleans. 
M.  ALLEN  STARR,  M.D.,  Professor  of  Nervous  Diseases  in  the  New  York  Polyclinic. 
HENRY  W.  STELWAGON,  M.D.,  Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases. 
GEORGE  M.  STERNBERG,  M.D.,  Major  and  Surgeon  U.  S.  Army. 

H.  LONGSTREET  TAYLOR,  M.D.,  Assistant  to  the  Chair  of  Surgery,  and  Physician  in  Children's 

Clinic,  Medical  College  of  Ohio,  Cincinnati. 
R.  W.  TAYLOR,  M.D.,  Surgeon  to  Charity  Hospital,  New  York. 

GEORGE  D.  THANE,  M.R.C.S.  Eng.,  Prof  essor  of  Anatomy  at  University  College,  London. 
FREDERICK  TREVES,  F.R.C.S.,  Surgeon  to,  and  Lecturer  on  Anatomy  at,  the  London  Hospital. 

E.  L.  TRUDEAU,  M.D.,  of  Saranac  Lake,  New  York. 

ELY  VAN  DE  WARKER,  M.D.,  Surgeon  to  the  Central  Hospital  for  Women,  Syracuse,  N.  Y. 
WILLIAM  H.  WELCH,  M.D.,  Professor  of  Pathology  in  the  Johns  Hopk'ms  University. 
RANDOLPH  WINSLOW,  M.D.,  Professor  of  Surgery  in  the  Woman's  Medical  College  of  Baltimore. 
GERALD  F.  YEO,  M.D.,  Prof  essor  of  Physiology  at  King' s  College,  London. 


TO  READERS  AND  CORRESPONDENTS. 


All  communications  intended  for  insertion  in  the  Original  Department  of  this  Journal  are  only 
received  with  the  distinct  understanding  that  they  are  sent  for  publication  to  this  Journal  alone. 
Gentlemen  favoring  us  with  their  communications  are  considered  to  be  bound  in  honor  to  a  strict 
observance  of  this  understanding. 

Contributors  who  wish  their  articles  to  appear  in  the  next  number  are  requested  to  forward  them 
before  the  15th  of  November  to  the  Editor,  No.  1004  Walnut  Street,  Philadelphia, 

Liberal  compensation  is  made  for  articles  used.  Extra  copies,  in  pamphlet  form  with  cover,  will 
be  furnished  to  authors  in  lieu  of  compensation,  provided  the  request  for  them  be  written  on  the  manuscript. 

The  following  works  have  been  received  for  review  : 

A  System  of  Gynecology  by  American  Authors.  Edited  by  Matthew  D.  Mann,  A.M.,  M.D.,  Pro- 
fessor of  Obstetrics  and  Gynecology  in  the  University  of  Buffalo,  N.  Y.  Vol.  I.  Philadelphia :  Lea 
Brothers  &  Co.,  1887. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Exercise.  By  Joseph  Schbeiber,  M.D., 
Member  of  K.  K.  Gesellschaft  der  Aerzte  of  Vienna.  Translated,  with  the  author's  permission,  by 
Walter  Mendelson,  M.D.,  of  New  York.    Philadelphia  :  Lea  Brothers  &  Co.,  1887. 

The  Student's  Guide  to  Diseases  of  the  Eye.  By  Edward  Nettleship,  F.R.C.S.  Third  American 
from  the  Fourth  English  Edition.  With  a  Chapter  on  Examination  for  Color  Perception.  By  Wil- 
liam Thomson,  M.D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College  of  Philadelphia. 
Philadelphia  :  Lea  Brothers  &  Co.,  1887. 

Syphilis.    By  Jonathan  Hutchinson,  F.R.C.S.,  LL.D.    Philadelphia:  Lea  Brothers  &  Co  ,  1887. 

Druitt's  Surgeon's  Vade-Mecum.  A  Manual  of  Modern  Surgery.  Edited  by  Stanley  Boyd,  M.D., 
B.S.  Lond.,  F.R.C.S.  Eng.    Twelfth  edition.    Philadelphia  :  Lea  Brothers  &  Co.,  1887. 

A  Practical  Treatise  on  Diseases  of  the  Eye.  By  Dr.  Edward  Meyer,  Prof,  a  1'Ecole  Pratique  de  la 
Faculte  de  Medecine  de  Paris.  Translated  by  Freeland  Fergus,  M.D.,  Ophthalmic  Surgeon,  Glasgow 
Royal  Infirmary.    Philadelphia:  P.  Blakiston,  Son  &  Co.,  1887. 

AbdomiDal  Surgery.  By  J.  Greig  Smith,  M.A.,  F.B.S.E.,  Surgeon  to  the  Bristol  Royal  Infirmary. 
Philadelphia:  P.  Blakiston,  Son  &  Co.,  1887. 

Diseases  of  Children.  By  Angel  Money,  M.D.,  M.R.C.P.,  Assistant  Physician  to  the  Hospital  fur 
Sick  Children,  Great  Ormond  Street,  and  to  the  Victoria  Park  Chest  Hospital.  Philadelphia  :  P.  Blak- 
iston, Son  &  Co.,  1887. 

Photographic  Illustrations  of  the  Anatomy  of  the  Human  Ear,  together  with  Pathological  Conditions 
of  the  Drum  Membrane.  By  B.  Alex.  Randall,  A.M.,  M.D.,  and  Henry  Lee  Morse,  B.A.,  M.D. 
Philadelphia  :  P.  Blakiston,  Son  &  Co.,  1887. 

The  Principles  of  Antiseptic  Methods  Applied  to  Obstetric  Practice.  By  Dr.  Paul  Bar,  Accoucheur 
to  the  Maternity  Hospital,  Paris.  Translated  by  Henry  D.  Fry,  M.D.  Philadelphia :  P.  Blakiston, 
Son  &  Co.,  1887. 

Outlines  for  the  Management  of  Diet.  Practical  Lessons  in  Nursing.  By  Edward  Tunis  Bruen, 
M.D.,  Assistant  Professor  of  Physical  Diagnosis,  University  of  Pennsylvania,  etc.  Philadelphia  :  J.  B. 
Lippincott  Co.,  1887. 

Transactions  of  the  American  Gynecological  Society.  Vol.  II.  For  the  year  1886.  New  York  : 
Appleton  &  Co.,  1887. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American  Laryngological  Association.  New  York  : 
Appleton  &  Co.,  1887. 

The  Curability  of  Insanity,  and  the  Individualized  Treatment  of  the  Insane.  By  John  S.  Butler, 
M.D.,  Hartford  Conn.,  late  Physician  and  Superintendent  of  the  Connecticut  Retreat  for  the  Insane, 
etc.    New  York  and  London  :  G.  P.  Putnam's  Sons,  1887. 

Autobiography  of  Samuel  D.  Gross,  M.D.,  D.C.L.  Oxon.,  LL.D.  Cantab.,  Edin.,  Jeff.  Coll.,  Univ.  Pa., 
Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia  ;  with  Sketches  of  his 
Contemporaries.    Edited  by  his  Sons.    In  two  volumes.    Philadelphia  :  George  Barrie,  1887. 

Practical  Urine  Testing.  By  Charles  Godwin  Jennings,  M.D.,  Professor  of  Chemistry  and  Diseases 
of  Children,  Detroit  College  of  Medicine.    Detroit :  D.  0.  Haynes  &  Co.,  1887. 

The  Cremation  of  the  Dead  considered  from  an  iEsthetic,  Sanitary,  Religious,  Historical,  Medico- 
Legal,  and  Economical  Standpoint.  By  Hugo  Erichsen,  M.B.  With  an  Introductory  Note  by  Siu  T. 
Spencer  Wells,  Bart.,  F.R.S.    Detroit :  D.  0.  Haynes  &  Co.,  1887. 

Elements  of  Botany.  By  Edson  S.  Bastin,  A.M.,  F.R.M.S.,  Prof,  of  Botany,  Materia  Medica,  ami 
Microscopy  in  the  Chicago  College  of  Pharmacy.    Chicago  :  G.  P.  EDgelliard  &  Co.,  1887. 


308 


TO  READERS  AND  CORRESPONDENTS. 


A  Theoretical  and  Practical  Treatise  on  Astigmatism.    By  Swan  M.  Burnett,  M.D.,  Professor  of 
Ophthalmology  and  Otology  in  the  University  of  Georgetown,  etc.    St.  Louis  :  J.  H.  Chambers  &  Co. 
1887. 

A  Treatise  on  Diphtheria,  Historically  Considered;  including  Croup,  Tracheotomy,  and  Intubation. 
By  A.  Sanne.  Translated  and  Annotated  by  Henry  Z.  Gill,  A.M.,  M.D.  St.  Louis  :  J.  H.  Chambers 
&  Co.,  1887. 

Report  on  the  Mortality  and  Vital  Statistics  of  the  United  States  as  returned  at  the  Tenth  Census 
(June  1,  1880).    By  John  S.  Billings,  Surgeon  U.  S.  Army.    Part  II.    "Washington,  1886. 

Plates  and  Diagrams  accompanying  Part  II.  of  the  Report  on  Mortality  and  Vital  Statistics. 

The  Farmer's  Veterinary  Adviser.  By  James  Law,  Professor  of  Veterinary  Science  in  Cornell  Uni- 
versity.   Published  by  the  author.    Ithaca,  1887. 

What  to  do  in  Cases  of  Poisoning.  By  William  Murrell,  M.D.,  M.R.C.P.,  Lecturer  on  Pharma- 
cology and  Therapeutics  in  the  Westminster  Hospital,  etc.  First  American  from  the  Fifth  English 
edition.    Published  by  the  Medical  Register  Company.    Philadelphia,  1887. 

Lectures  on  the  Surgical  Disorders  of  the  Urinary  Organs.  By  Reginald  Harrison,  F.R.C.S. 
Third  edition.    London  :  J.  &  A.  Churchill,  1887. 

Health-Resorts  at  Home  and  Abroad.  By  M.  Charteris,  M.D.,  Professor  of  Therapeutics  and 
Materia  Medica,  Glasgow  University.    London  :  J.  &  A.  Churchill,  1887. 

Practitioner's  Handbook  of  Diseases  of  the  Ear  and  Naso-Pharynx.  By  H.  MacNaughton  Jones, 
M.D.,  M.Ch.,  M.A.O.  (Hon.),  etc.    London :  J.  &  A.  Churchill,  1887. 

De  la  Jugulation  de  la  Fievre  Typhoide  en  moyen  de  la  Quinine  et  des  Bains  Tiedes.  Par  Dr. 
Pecholier,  Professeur  Agrege  a  la  Faculte  de  Medecine  de  Montpellier.  Paris  :  Delahaye  &  Lecros- 
nier,  1887. 

Congres  Periodique  International  des  Sciences  Medicales.  8me  Session.  Copenhague,  1884.  Copen- 
hague  :  Libraire  Glydendal  (F.  Hegel  &  Fils),  1886. 

Lecons  sur  les  Fonctions  Matrices  du  Cerveau.  Par  le  Dr.  Francois-Franck,  Directeur  Adjunct  du 
Laboratoire  de  Physiologie  de  l'Ecole  des  Hautes-Etudes,  Professeur  remplacant  au  College  de  France 
Paris  :  Octave  Doin,  Editeur,  1887. 

L'Annee  Medicale,  1886.  Publie  sans  la  direction  du  Dr.  Bourneville.  Paris :  E.  Plon,  Nourrit 
et  Cie,  1887. 

Lehrbuch  der  Allgemeinen  und  Speciellen  Pathologischen  Anatomie,  fur  Aerzte  and  Studirende. 
Von  Dr.  Erxst  Ziegler,  Prof,  der  Path.  Anat.  und  der  Allgemein.  Pathol,  an  der  Universitat  Tubin- 
gen. Zwei  Bande.    Jena  :  Gustav  Fischer,  1887. 

Handbuch  der  Physiologischen  Optik.  Von  H.  von  Helmholtz.  Zweite  umgearbeitete  Aufiage. 
Vierte  Lieferung.    Hamburg  und  Leipzig  :  Verlag  von  Leopold  Voss,  1887. 

Lehrbuch  der  Physiologie  fur  Akademische  Vorlesungen  und  Selbststudium  Begrundet  von  Rud. 
Wagner,  fortgefiihrt  von  Otto  Funke,  neu  herausgegeben  von  Dr.  A.  Gruenhagen,  Professor  der 
Medizin  u.  Physik  an  der  Universitat  zu  Konigsberg.  Dreizehnte  Lieferung  (Schluss  des  Werkes). 
Hamburg  und  Leipzig  :  Verlag  von  Leopold  Voss,  1887. 

Die  Geschichte  der  Laryngologie  von  der  friihesten  Zeiten  bis  zur  Gegenwart.  Von  Dr.  Gordon 
Holme,  in  London.  Aus  dem  Englischen  ubersetzt  von  Dr.  Otto  Koerner.  Berlin  :  August  Hirsch- 
wald,  1887. 

Neuerungen  und  Verbesserungen  in  der  application  der  Fracturen  beharilung.  Von  Dr.  Aug. 
Schreiber,  Oberarzt  am  stadt-Krankenhaus  in  Augsburg.    Bern,  1887. 

Zur  Localen  Behandlung  der  Blase.  Ueber  Polyurie,  Anurie,  und  Oligurie.  Zwei  Abhandlungen. 
Von  Prof.  Dr.  Robert  Ultzmann,  in  Wien.    Wien  :  M.  Breitenstein,  1887. 

BeobachtuDgen  tiber  malaria  inbesondere  das  Typhoide  malaria  fieber.  Von  Dr.  P.  Werner, 
Narva.    Berlin:  August  Hirschwald,  1887. 

Trattato  Delia  Difteria  per  il  Cav.  Dott.  Vincenzo  Cozzolino,  Prof,  pareg.  della  R.  Universita  di 
Napoli.    Napoli,  1887. 

Caso  Classico  di  Osteomalacia  Maschile.  Considerazione  E.  Ricerche  del  Dott.  Carlo  Burani,  Tesi 
di  Laurea.    Modena,  1887. 

Do  Valor  Therapeutico  de  Alguns  Etsocraticos  no  Impaludisma  Agudo.  Pelo  Dr.  Tiberio  d' Almeida, 
Redactor  correspondente  da  Uniao  Medica,  etc.    Rio  de  Janeiro  :  Lombaerts  &  Co.,  1887. 

A  Questao  Dos  Vinhos  (os  vinohs  Falsificados).    Pelo  Dr.  Campos  da  Paz.    Rio  de  Janeiro,  1886. 

Studies  from  the  Biological  Laboratory  of  Johns  Hopkins  University,  Baltimore.    June,  1887. 

First  and  Second  Special  Reports  upon  the  Improvements  in  the  Scale  of  Diet  in  the  Imperial 
Japanese  Navy  for  1884  and  1885. 


CONTENTS. 


ORIGINAL  COMMUNICATIONS. 

PAGE 

Contusion  of  the  Abdomen,  with  Rupture  of  the  Intestine.  Being  the 
Essential  Part  of  an  Essay  awarded  the  Cartwright  Prize  of  the  Alumni 
Association  of  the  College  of  Physicians  and  Surgeons,  of  New  York. 
By  B.  Farquhar  Curtis,  M.D.,  Assistant  Surgeon  to  the  New  York 
Cancer  Hospital     .       .       .  321 

On  Hepatic  Cirrhosis  in  Children.  By  R.  Palmer  Howard,  M.D., 
L.R.C.S.  Ed.,  LL.D.,  Professor  of  Medicine  in  McGill  University, 
Montreal   .  .  350 

On  the  Therapeutic  Action  of  the  Sulphate  of  Spartein.  By  J.  Mitch- 
ell Clarke,  M.A.,  M.D.  Cantab.,  Assistant  Physician  to  the  Bristol 
General  Hospital;  Assistant  Lecturer  on  Physiology  at  the  Bristol 
Medical  School  363 

The  Cardiac  Relations  of  Chorea.  By  William  Osler,  M.D.,  Professor 
of  Clinical  Medicine  in  the  University  of  Pennsylvania  ;  Physician  to 
the  University  Hospital,  to  the  Philadelphia  Hospital,  and  to  the  In- 
firmary for  Nervous  Diseases  371 

Hereditary  Tremor.  A  Hitherto  Undescribed  Form  of  Motor  Neurosis. 
By  C.  L.  Dana,  A.M.,  M.D.,  President  of  the  New  York  Neurological 
Society,  Visiting  Physician  to  Bellevue  Hospital,  Professor  of  Nervous 
and  Mental  Diseases,  New  York  Post-Graduate  Medical  School  .       .  386 

The  Dyspnoea  of  Asthma  and  Bronchitis :  its  Causation,  and  the  Influence 
of  Nitrites  upon  it.  By  Thomas  R.  Fraser,  M.D.,  F.R.S.,  F.R.C.P.E., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  University 
of  Edinburgh        .       .       .  393 

Neuralgic  Headaches  with  Apparitions  of  Unusual  Character.  By  S. 
Weir  Mitchell,  M.D.,  Physician  to  the  Infirmary  for  Nervous  Dis- 
eases, Philadelphia  415 

Atrophy  of  the  Gastric  Tubules  :  its  Relations  to  Pernicious  Anosmia.  By 
F.  P.  Kinnicutt.  M.D.,  Physician  to  St.  Luke's  Hospital  and  the  New 
York  Cancer  Hospital,  New  York  41  (J 

A  Case  of  Subcutaneous  Nodules  in  the  Hands  of  a  Rheumatic  Patient. 
By  George  S.  Middleton,  M.A.,  M.D.,  Assistant  Physician  to  the 
Royal  Infirmary,  Glasgow;  Assistant  to  the  Professor  of  Practice  of 
Physic,  University  of  Glasgow  433 


310 


CONTENTS. 


PAGE 


Circular  Suture  of  the  Intestine — an  Experimental  Study.  By  William 
S.  Halsted,  M.D.,  of  New  York  436 

Primary  Malignant  Degeneration  of  the  Kidney  in  Infancy.  By  H. 
Longstreet  Taylor,  A.M.,  M.D.,  Assistant  to  the  Chair  of  Surgery, 
and  Physician  in  the  Children's  Clinic,  Medical  College  of  Ohio,  Cin- 
cinnati   .  .       .  461 

A  Consideration  of  the  Eesults  in  327  Cases  of  Tracheotomy,  performed 
at  the  Boston  City  Hospital  from  1864  to  1887.  By  Robert  W.  Lovett, 
M.D.,  and  John  C.  Munro,  M.D.,  formerly  House  Surgeons  at  the 
Hospital   .  476 


REVIEWS. 

Autobiography  of  Samuel  D.  Gross,  M.D.,  D.C.L.  Oxon.,  LL.D.  Cantab., 
Edin.,  Jeff.  Coll.,  Univ.  of  Pa.,  Emeritus  Professor  of  Surgery  in  the 
Jefferson  Medical  College  of  Philadelphia.  With  Sketches  of  his  Con- 
temporaries.   Edited  by  his  Sons  479 

Hemorrhagies  Uterines,  Etiologie,  Diagnostic,  Traitement.  Par  le  Doc- 
teur  Sneguireff,  Professeur  de  Gynecologie  a  l'Universitelmperiale 
de  Moscou.  Edition  Francaise  redigee  par  M.  H.  Varnier,  Interne 
des  Hopitaux  de  Paris,  sous  la  direction  de  M.  le  Docteur  Pinard, 
Professeur  Agrege  a  la  Faculte  de  Paris,  Accoucheur  de  l'Hopital 
Laraboisiere. 

The  Etiology,  Diagnosis,  and  Treatment  of  Uterine  Hemorrhages.  By 


Doctor  Sneguireff  .  493 

Dermatitis  Venenata :  an  Account  of  the  Action  of  External  Irritants 
upon  the  Skin.  By  James  C.  White,  M.D.,  Professor  of  Dermatology, 
Harvard  University   498 

Researches  upon  the  Venom  of  Poisonous  Serpents.  By  S.  Weir  Mitch- 
ell, M.D.,  Member  of  the  National  Academy  of  Sciences,  U.  S.  A., 
President  of  the  College  of  Physicians  of  Philadelphia,  and  Edward 
T.  Reichert,  M.D.,  Professor  of  Physiology  in  the  University  of  Penn- 
sylvania  500 

Lecons  sur  les  Maladies  du  Systeme  Nerveux  faites  a  la  Salpetriere.  Par 
J.  M.  Charcot,  Professeur  a  la  Faculte  de  Medecine  de  Paris,  etc. 

Lectures  on  Diseases  of  the  Nervous  System  delivered  at  the  Salpetriere 
Hospital.    By  Prof.  J.  M.  Charcot  503 


A  Theoretical  and  Practical  Treatise  on  Astigmatism.  By  Swan  M. 
Burnett,  M.D.,  Professor  of  Ophthalmology  and  Otology  in  the  Uni- 
versity of  Georgetown,  D.  C   .       .       .  505 


CONTENTS. 


311 


PAGE 

Lehrbuch  der  AUgemeinen  und  Speciellen  Pathologischen  Anatomie. 

By  Ernst  Ziegler,  Prof,  der  Pathologischen  Anatomie  und  der  Allge- 

meinen  Pathol ogie  an  der  Universitat  Tubingen. 
A  Text-book  of  Pathological  Anatomy  and  Pathogenesis.    By  Ernst 

Ziegler.    Translated  and  Edited  for  English  students  by  Donald 

MacAlister,  M.A.,  M.D   .  .507 

Abdominal  Surgery.  By  J.  Greig  Smith,  M.A.,  F.E.S.E.,  Surgeon  to 
the  British  Royal  Infirmary  ;  late  Examiner  in  Surgery,  University  of 
Aberdeen  ;  Fellow  of  the  Royal  Medical  and  Chirurgical  Society,  Lon- 
don, etc  509 

Transactions  of  the  American  Gynecological  Society,  for  the  Year  1886  .  511 

Der  Augenspiegel  und  die  Ophthalmoskopische  Diagnostik.    Von  Dr. 

F.  Dimmer,  Docent  in  d.  Wiener  Universitat,  etc. 
The  Ophthalmoscope  and  Ophthalmoscopic  Diagnosis.  By  Dr.  F.  Dimmer  513 

Hysterie  et  Traumatism.    Par  le  Dr.  Paul  Berbez. 

Hysteria  and  Traumatism.    By  Dr.  Paul  Berbez  ...  .  513 

The  Topographical  Anatomy  of  the  Child.  By  Johnson  Symington, 
M.D.,  F.R.S.E.,  Lecturer  on  Anatomy,  School  of  Medicine,  Edinburgh  515 

A  Practical  Treatise  on  Diseases  of  the  Eye.  By  Dr.  Edouard  Meyer, 
Prof,  a  l'Ecole  pratique  de  la  Faculte  de  Medecine  de  Paris,  etc.  Trans- 
lated, with  the  assistance  of  the  Author,  by  Freeland  Fergus,  M.B., 
Ophthalmic  Surgeon,  Glasgow  Royal  Infirmary,  etc  515 


QUARTERLY  SUMMARY 

OF  THE 

PKOGBESS  OF  MEDICAL  SCIENCE. 


ANATOMY. 
Under  the  charge  of  George  D.  Thane,  M.R.C.S.  Eng., 

Professor  of  Anatomy  at  University  College,  London. 


On  the  Synovial  Sheath  of  the  Radial  Extensors  of  the  Wrist.  By  Larger, 

Debierre  and  Rochet  517 

On  the  Nervous  Supply  of  the  Lumbricales.    By  H.  St.  John  Brooks     .  517 
On  the  Pharyngeal  Orifice  of  the  Eustachian  Tube.    By  Casimir  von 
Kostanecki  518 


312 


CONTENTS. 


MATERIA  MEDIC  A,  THERAPEUTICS,  AND 
PHARMACOLOGY. 

Under  the  charge  of  Roberts  Bartholow,  M.D.,  LL.D., 

Professor  of  Materia  Medica,  General  Therapeutics,  and  Hygiene  in  the  Jefferson  Medical  College,  Philadelphia. 


PAGE 

Stenocarpine;  a  New  and  Powerful  Anaesthetic  and  Analgesic  of  Indige- 
nous Source.    By  Mr.  Goodman,  Drs.  Allen  M.  Seward,  Claiborne,  and 


Knapp     .  519 

Solanin.    By  Dr.  Geneuil  520 

Effects  of  Hyoscine.    By  Kobert  521 

Injection  for  Gonorrhoea.    By  Delpech  521 

Massotherapy.    By  Dujardin-Beaumetz  522 

Hypnotism.    By  Gilles  de  la  Tourette  *  .  522 

Iodide  of  Potassium  in  the  Broncho-pneumonia  of  Children.    By  Dr. 

Zinis  523 

The  Actions  of  the  Crystallizable  Veratrum  Alkaloids.   By  Dr.  Heinrich 

Lissauer  523 

The  German  and  French  Treatment  of  Asthma  Compared.    By  Dr. 

Schlemner      .       .       .   524 

Ulexine.    By  Gerrard  and  Mr.  J.  Rose  Bradford  524 

Glycerine  and  Diabetes.    By  Mr.  W.  B.  Ransom  525 

Treatment  of  Angina  Pectoris.    By  Dr.  Huchard  525 

Hydroquinone.    By  Drs.  Silvestrini  and  Picchini    .....  526 

Mercurial  Paralysis.    By  M.  Maurice  Letulle  526 

Methylal.    By  Prof.  Anreps  527 

Action  of  Calomel  on  the  Bile.  By  Dr.  J.  Zawadzky  ....  527 
Calomel  as  a  Diuretic.   By  M.  Jendrassik   .  528 


MEDICINE. 
Under  the  charge  of  William  Osler,  M.D.,  F.R.C.P.  Lond., 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania. 
ASSISTED  BY 

J.  P.  Crozer  Griffith,  M.D.,  Walter  Mendelson,  M.D., 

Assistant  Physician  to  the  Hospital  of  the  University  Instructor  in  the  Laboratory  of  the  College  of 

of  Pennsylvania.  Physicians  and  Surgeons,  New  York. 


The  Value  of  Sudoral  Eruptions  as  a  Prognostic  Sign  in  Typhoid.  By 
Lacaze  528 

On  a  Method  of  Prophylaxis  and  an  Investigation  into  the  Nature  of  the 
Contagion  of  Scarlet  Fever.    By  Jamieson  and  Edington    .       .       .  528 


CONTENTS. 


313 


PAGE 


Hemiplegia  in  Children.    By  Abercrombie  530 

Periodic  Paralysis.    By  Cousot  531 

Landry's  Paralysis.    By  Mann  532 

The  Hereditary  Chorea  of  Adults  (Huntington's  Chorea).  By  Huber  .  534 
The  Pathogenesis  and  Treatment  of  Diabetic  Coma.  By  Lepine  .  .  535 
Contribution  to  the  Diabetic  Dyscrasia.  By  Hugounenq  .  .  .  535 
Parenchymatous  Myositis.  By  Hepp  and  Wagner  .  .  .  .  .  536 
Extreme  Frequency  of  the  Pulse  after  Paracentesis.  By  Dehio  .  .  538 
The  Etiology  of  Endocarditis.  By  Frankel  and  Sanger  ....  539 
Contribution  to  the  Determination  of  the  Percussion  Limits  of  the 

Stomach.    By  Pacanowski     ...  540 

Dysentery,  and  the  Meteorological  Conditions  Influencing  it.    By  Hip- 
pins  .       .  541 

Functional  Diseases  of  the  Liver.    By  Fenwick  542 

On  a  Peculiar  Occurrence  of  White,  Clay-colored  Stools.  By  Pel  .  .  543 
Cause  of  the  Red  Color  of  Non-saccharine  Urine  on  adding  Picric  Acid 

and  Potash.    By  Jaffe    .       .  544 

Two  New  Pathological  Coloring  Matters  in  Urine.    By  Leube  and  Thor- 

malen  545 

Cause  of  the  Development  of  Sulphuretted  Hydrogen  in  Urine.  By 
Rosenheim,  Rattone,  and  Valenta   545 


SURGERY. 

(Of  EUROPE.) 


Under  the  charge  of  Frederick  Treves,  F.R.C.S., 

Surgeon  to,  and  Lecturer  on  Anatomy  at,  the  London  Hospital. 


Recent  Surgical  Literature  545 

Abdominal  Section.   By  Sir  William  MacCormac,  M.  Fenillon,  Dr.  Rock- 

witz,  Mr.  Williamson,  C.  Stonham,  and  Dr.  Rehn  ....  549 
The  Treatment  of  Intussusception.    By  Mr.  Barker,  Mr.  Dent,  and  Mr. 

Knaggs  549 

Resections  and  Amputations.   By  Dumont  549 

Fractures  and  Dislocations.    By  M.  Hennequin  549 

Charcot's  Joint  Disease.    By  Prof.  Sonnenburg,  Prof.  Westphal,  and 

Jurgens    550 

Operations  on  the  Kidneys  and  Bladder.  By  A.  Edel,  Koch,  E.  de  Paoli, 

F.  Bereskin,  M.  Terrier,  Mr.  Morgan,  Mr.  Whitehead,  Mr.  Harrison, 

Mr.  Greenwood,  Sir  Henry  Thompson,  Mr.  Edmund  Owen,  Mr.  Imlach, 

and  Mr.  R.  J.  Godlee  552 

Tumors.    By  Messrs.  Shattock  and  Ballance,  Drs.  Fischer,  Hildebrand, 

and  Wassermann  552 


314 


CONTENTS. 


PAGE 


Operations  on  the  Gall-bladder,  etc.    By  Mr.  Page  553 

Dupuytren's  Contraction.    By  Prof.  Kocher  553 

Diseases  of  the  Jaws.    By  Mr.  Christopher  Heath    .       ...       .       .  553 

Mercurial  Injections  in  Syphilis.    By  M.  Martineau       .       .       .       .  554 

"  Hammer-toe."  By  Mr.  Anderson,  MM.  Terrier,  Verneuil,  Lannelongue, 

Howard,  Marsh,  and  Lucy  554 

Cleft-palate.    By  M.  Le  Bee,  M.  Broca,  and  Dr.  Morian  ....  555 
Synovial  Cysts  in  the  Neighborhood  of  the  Knee.    Ly  Mr.  Mayo  Bob- 
son,  M.  Poinier,  and  Mr.  Morrant  Baker  555 

Surgical  Dressings.    By  von  Mosetig  Moorhof,  de  Ruyter,  Senger,  and 

Prof.  P.  Burns  555 

A  New  Operating  Table.    By  Dr.  Hagedorn  555 

Injuries  of  Nerves.  By  Mr.  A.  Bowlby  and  M.  Polaillon  .  .  .  556 
Mycosis  Fungoides.    By  H.  Hobner,  Hochsinger,  and  Schiff  .       .       .  556 

Diseases  of  the  Rectum.    By  Mr.  Whitehead  556 

(Esophagotomy.    By  Dr.  G.  Fischer  and  Mr.  Bennet  May      .       .       .  556 

Hydatid  Cysts.    By  Drs.  Gardner  and  Thomas  557 

Hydrophobia  557 

Recent  Notable  Papers      .       .       .       .       .       ....       .  558 


(IN  AMERICA.) 


Excision  of  the  Larynx  and  Pharynx.  By  Dr.  D.  Hayes  Agnew  .  .  559 
Middle  Meningeal    Hemorrhage — Treatment  by  Trephining.    By  Dr. 

Charles  A.  Powers  f  559 

Trephining  in  a  Case  of  Intermeningeal  Hsematoma  with  Hemiplegia. 

By  Dr.  S.  T.  Armstrong   .       .  .560 

Laparotomy  for  Perforation  of  the  Appendix  Vermiformis.  By  Dr.  R.  F. 

We-  561 

Laparotomy  for  Perforating  Pistol-shot  Wound  of  the  Abdomen.  By  Dr. 

J.  I.  Skelley   ...  562 

Splenectomy.    By  Dr.  J.  W.  Leonard  562 

Suprapubic  Cystotomy.    By  Dr.  F.  S.  Dennis  563 

Treatment  of  Anal  Fissure  and  Hemorrhoids  by  Gradual  Dilatation.  By 

Dr.  H.  O.  Walker  564 

Horny  Growth  of  the  Penis.  By  Dr.  J.  H.  Brinton  ....  564 
The  Correction  of  "  Pug-nose  "  by  a  Simple  Operation.    By  Dr.  John  O. 

Roe  565 

Amputation      the  Breast  under  Cocaine  Anaesthesia.    By  Dr.  Daniel 

Lewis     .       .     .  .     ...       .      ( .       .       ...       .       .  565 

Ligature  of  the  Internal  Jugular  Vein  for  a  Knife-cut.     By  Dr.  F. 

Tipton   .       .  .565 

Base-ball  Pitcher's  Arm.    By  Dr.  A.  H.  P.  Leuf  566 


CONTENTS. 


315 


OPHTHALMOLOGY. 
Under  the  charge  of  L.  Webster  Fox,  M.D., 

Ophthalmic  Surgeon  to  the  Germantown  Hospital,  Philadelphia. 


PAGE 


Etiology  of  Ocular  Paralyses.    By  Prof.  Foumier  566 

The  Bacillus  of  Catarrhal  Conjunctivitis.  By  Dr.  J.  E.  Weeks  .  .  567 
Tuberculosis  of  the  Conjunctiva.    By  Dr.  Stolting   .       .       .  .  567 

Injuries  of  the  Eyes  by  Dynamite.    By  Professor  A.  von  Hippel     .       .  567 

Ocular  Injury  by  Lightning.    By  Dr.  M.  Knies  568 

Relations  of  Corneal  Curvature  to  Cranial  Circumference.    By  Bourgeois 

and  Tscherning  568 

Irido-cyclitis  Tuberculosa.  By  Dr.  August  Wagenmann  ....  568 
The  Pupillary  Immobility  of  Progressive  Paralysis.  By  Moelli  .  .  569 
The  Relation  between  Choroidal  Crescent  and  Astigmatism.    By  Georges 

Martin  '.    "  .       .       .       .    '  .       .  569 

Cases  of  Primary  Glaucoma  in  the  Young.  By  Dr.  O.  Lange  .  .  .  569 
The  Pathological  Anatomy  of  Glaucoma.  By  Birnbacher  and  Czermak  570 
The  Influence  of  Mydriatics  and  Myotics  upon  Intraocular  Pressure.  By 

Dr.  Friederich  Stocker   .       .       .       .       .       .       .       .       .       .  571 

Subconjunctival  Scleral  Fistula  in  Glaucoma.  By  M.  Motais  .  .  .  571 
The  Spontaneous  Absorption  of  Senile  Cataract.    By  Dr.  Paul  Meyer 

and  Dr.  Charles  J.  Kipp  572 

The  Relation  of  Accommodation-Strain  to  Glaucoma  and  Cataract.  By 

Dr.  W.  Schoen   .  .572 

Yisual  Disturbances  Resulting  from  Cauterization  of  the  Nasal  Passages. 

By  E.  Berger  and  Dr.  Zien  573 

Epidemic  Hemeralopia.    By  Dr.  Theodore  Kubli  573 

Miner's  Nystagmus.    By  C.  S.  Jeaffreson  574 

Report  of  500  Enucleations  of  the  Eyball.  By  Dr.  d'Oench  .  .  .  574 
The  Influence  of  Chronic  Alcoholism  upon  the  Eve.    Bv  Dr.  W.  Uhthoff  574 


OTOLOGY. 
Under  the  charge  of  Charles  H.  Burnett,  M.D., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medicine,  etc. 


Mastoid  Operations.    By  Dr.  Albert  H.  Buck  577 

Foreign  Bodies  in  the  Ear.    By  Dr.  Charles  Delstanche  ....  578 

Boxing  the  Ears.    By  Dr.  Samuel  Sexton  580 

Chronic  Purulent  Inflammation  of  the  Tympanic  Attic.    By  Dr.  EL  N. 
Spencer  .  582 


316 


CONTENTS. 


DISEASES  OF  THE  LARYNX  AND  CONTIGUOUS 
STRUCTURES. 

Under  the  charge  of  J.  Solis-Cohen,  M.D., 

Professor  of  Diseases  of  the  Throat  and  Chest,  Philadelphia  Polyclinic. 


PAGE 

Mould- fungi  as  Causes  of  Diphtheria.  By  Dr.  Michael  W.  Taylor  .  .  584 
Unusual  Cutaneous  Pigmentation  in  Diphtheria.    By  Werner       .       .  584 

Atrophic  Rhinitis.    By  Dr.  Delavan  584 

Removal  of  Nasopharyngeal  Tumor  after  Resection  of  the  Superior  Max- 
illa.   By  Dr.  Nathan  Jacobson  584 

Ozsena.    By  Habermann   .  585 

Tuberculous  Tumors  of  the  Nasal  Mucous  Membrane.    By  Dr.  Max 

Schaeffer  and  Dr.  Dietrich  Nasse  585 

Nasal  Vertigo.    By  Dr.  Joal  586 

The  Pathological  Nasal  Reflex.  By  Dr.  John  Noland  Mackenzie  .  .  586 
Relief  of  Congestive  Headaches  by  Intranasal  Scarification.    By  Dr. 

Glasgow.      .      .      .      .       .      .      •      .  T.  .586 

Empyema  of  the  Antrum.    By  Dr.  B.  Frankel  587 

Death  from  (Edema  of  the  Larynx  shortly  after  Birth.  By  H.  Vogt  .  587 
Sudden  Death  from  (Edema  of  the  Larynx  in  an  Adult.    By  Dr.  B. 

Frankel   .  587 

Topical  Cures  of  the  Tuberculous  Larynx.  By  Prof.  Gougenheim  .  .  588 
Swallowing  Rendered  Easy  in  Tuberculosis  of  Larynx.   By  Dr.  R.  Norris 

Wolfenden  58g 

Lupus  of  the  Larynx.    By  Dr.  Michael  Grossmann        ....  588 

Cysts  of  the  Larynx.    By  Dr.  J.  Garel  590 

Laryngeal  Polyp  Removed  with  the  Finger-nail  after  Laryngofissure. 

By  Dr.  Franz  Schopf  590 

Pachydermia  Laryngis.    By  Virchow  590 

Accidental  Intubation  of  the  Larynx  in  the  Passage  of  the  Stomach  Tube. 

By  Dr.  Coustoux  591 

Intubation  of  the  Larynx.    By  Prof.  Carl  Stork,  Drs.  Ingalls  and  Sajous  592 

Laryngectomy.    By  Hahn  and  Cohn   592 

A  Modified  Laryngectomy.  By  Dr.  J.  Solis  Cohen  ....  592 
Aneurismal  Pressure  on  Pneumogastric  and  Recurrent  Laryngeal  Nerves. 

By  Dr.  David  Newman  593 

Topical  Medication  of  the  Trachea  and  Bronchi.  By  Dr.  Max  Schaeffer  593 
Carcinoma  of  the  Thyroid  Gland,  and  its  Typical  Anatomical  Course. 

By  Dr.  D.  Aigre     .       .       .  594 


CONTENTS.  317 


DERMATOLOGY. 
Under  the  charge  of  Louis  A.  Duhrixg,  M.D., 

Professor  of  Dermatology  in  the  University  of  Pennsylvania, 
AND 

Henry  W.  Stelwagon,  M.D., 

Physician  to  the  Philadelphia  Dispensary  for  Skin  Diseases. 


PAGE 

The  Etiology  of  Impetigo,  Furuncle,  and  Sycosis.    By  Bockhart    .       .  595 

Leprosy  and  Vaccination.    By  Gairdner  596 

Pruritus  Hiemalis.    By  Payne  596 

Naphthol.    By  Allen        .       .       .       .  596 

Ichthyol  and  Resorcin :  a  Clinical  Study  of  their  Effects.    By  Jackson  .  597 

Herpes  Digitalis.    By  Blaschko        .       .  597 

A  Case  of  Chronic  Dysidrosis  of  the  Face.    By  Rosenthal       .       .       .  598 
Eruption  from  Internal  Use  of  Arsenic.    By  Dr.  Leontowitsch       .       .  598 
On  the  Contagiousness  of  Tinea  Versicolor.    By  Huble   ....  598 

A  Case  of  Pemphigus  Cured  by  Applications  of  Oleate  of  Mercury.  By 
Crippe    .       .       .       .       .       .       ...       .       .       .  .599 

The  Pathology  of  Lichen  Ruber.    By  Kobner  .599 


MIDWIFERY  AND  GYNECOLOGY. 
Under  the  charge  of  D.  Berry  Hart,  M.D.,  F.R.C.P.E., 

Lecturer  on  Midwifery  and  Diseases  of  Women,  Surgeon's  Hall,  Edinburgh,  etc. 


Massage  in  Gynecology.    By  Profenter     .       .       .  .  .       .       .  600 

Insanity  and  Oophorectomy.    By  Lesynsky  601 

On  Extraperitoneal  Extirpation  of  the  Uterus.  By  Frank  .  .  .  601 
On  a  Case  of  Spontaneous  Inversion  of  the  Uterus.  By  Dr.  N.  T.  Brenis  601 
The  Application  of  Cocaine  in  Plastic  Gynecological  Operations.  By 


Kiistner  602 

The  Constitutional  Treatment  of  Puerperal  Sepsis.    By  Runge       .  .602 

On  Placenta  Prsevia.    By  Bayer  '.       .       .  <>,,;>> 

A  Contribution  to  the  Anatomy  of  the  Post-partum  Uterus,  with  Special 

Reference  to  Placenta  Proevia.    By  Hart  6041 

Internal  Puerperal  Erysipelas.    By  Winckel  ';i>4 

Cattle-horn  Lacerations  of  the  Abdomen  and  Uterus  in  Pregnant  Women. 

By  Harris  606 


318 


CONTENTS. 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

Under  the  charge  of  Matthew  Hay,  M.D., 

Professor  of  Medical  Jurisprudence,  University  of  Aberdeen. 

PAGE 

Rupture  of  the  Umbilical  Cord  at  Birth.    By  P.  Budin   .       .       .  .607 

Detection  of  Spermatozoa  in  Spermatic  Stains.    By  Ungar     .       .       .  607 
Detection  of  Phosphorus  in  a  Body  Three  Months  after  Death.  By 
Poleck    .      ...      .      .      ...........      .      .  .608 

Toxicity  of  Acetylene.    By  J.  Ogier  608 


PUBLIC  HEALTH. 
Under  the  charge  of  Shirley  F.  Murphy,  M.R.C.S., 

Lecturer  on  Hygiene  and  Public  Health,  St.  Mary's  Hospital,  London. 


Milk  Infection.    By  Dr.  Klein,  Mr.  William  Brown,  and  Dr.  W.  J. 

Simpson  .   .609 

Animal  Lymph  in  Berlin   611 


THE  MONTHLY  ISSUE 

OF 

THE  AMERI^MN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 


With  the  coming  of  1888  The  American  Journal  of  the  Medical 
Sciences  will  be  published  at  the  beginning  of  every  month,  instead  of 
quarterly,  as  heretofore.  This  change,  though  simply  told,  is  one  of 
deep  significance.  To  readers  it  means  a  trebled  frequency  of  commu- 
nication with  the  leading  thinkers,  workers,  and  discoverers  among  their 
colleagues ;  to  contributors  it  means  a  threefold  more  rapid  and  a  far 
wider  dissemination  of  their  thought ;  to  The  Journal  it  assures  an 
ever  broadening  circle  of  influence ;  and  lastly,  to  those  engaged  in  the 
executive  work  it  implies  a  vastly  increased  amount  of  labor.  Such  a 
change,  however,  is  simply  in  accordance  with  the  spirit  of  the  age. 
Never  before  were  so  many  earnest  workers  engaged  in  all  the  fields  of 
medical  research,  nor  at  any  previous  time  have  well-merited  honors 
so  surely  crowned  unselfish  labor  in  behalf  of  humanity.  One  potent 
cause  of  this  state  of  things  may  be  seen  in  the  enormous  mental  stimu- 
lus afforded  by  the  modern  possibility  of  reducing  medicine  to  an  exact 
science  by  coordinating  and  tracing  the  causation  and  effect  of  hitherto 
isolated  empirical  facts,  through  the  employment  of  instruments  c  °  pre- 
cision. These  immense  strides  have  now  become  such  matters  of  fact 
that  it  is  hard  to  realize  that  they  are  all  comprehended  within  the  life 
of  this  Journal.  Yet  ^e  have  it  from  the  pen  of  an  eminent  medical 
bibliographer  that  "  from  this  file  alone,  were  all  other  productions  of 
the  press  for  the  last  fifty  years  destroyed,  it  would  be  possible  to  repro- 
duce the  great  majority  of  the  real  contributions  of  the  world  to  medical 
science  during  that  period."  Such  a  record,  though  legitimately  a  sub- 
ject for  pride,  is  here  only  referred  to  as  a  pledge  that  The  Journal, 
though  crowned  with  honorable  years  and  achievements,  will  enter  upon 


320 


the  development  of  its  new  and  enlarged  possibilities  with  the  vigor  of 
youth  and  the  mature  experience  gained  through  two  generations. 

In  the  adoption  of  a  monthly  form  certain  changes  are  implied. 
Though  the  aggregate  of  space  will  be  somewhat  greater,  and  though  a 
larger  proportion  will  be  devoted  to  Original  Articles,  it  will  be  pre- 
sented in  smaller  divisions,  and  therefore  brevity  will  become  a  virtue 
ranking  second  solely  to  merit.  It  is  but  fair  that  every  reader  should 
find  in  each  number  something  of  interest  to  himself,  and  if  necessary, 
lengthy  articles  of  value  may  be  divided  among  successive  issues  in 
order  to  attain  this  end.  Of  the  remaining  two  departments  that  of 
Progress  will  undergo  no  change.  It  has  proved  itself  of  great  value, 
and  no  advisable  alteration  has  suggested  itself  after  diligent  consider- 
ation. To  accommodate  the  increased  amount  of  space  allotted  to 
Original  Communications,  the  Reviews  will  be  condensed,  yet  with  the 
maintenance  of  that  judicial  spirit  which  has  always  looked  alone  to 
the  interest  of  the  profession. 

In  its  new  form  The  Journal  will  become  more  than  ever  the 
favorite  medium  for  presenting  articles  requiring  some  elaboration,  and 
in  connection  with  the  weekly  Medical  News,  it  will  furnish  all  prac- 
titioners and  specialists  with  a  complete  and  well-digested  knowledge  of 
the  real  life  of  the  science.  Such  is  the  confidence  of  the  managers  of 
The  Journal  that  their  enterprise  will  be  appreciated,  that  they  have 
decided  to  accompany  the  new  departure  with  a  notable  reduction  in  the 
rate  of  subscription,  details  regarding  which  will  be  found  in  the  adver- 
tising pages  preceding  this  announcement. 


THE 

AMERICAN  JOURNAL 
OF  THE  MEDICAL  SCIENCES. 

OCTOBER,  1  88  7. 


CONTUSION  OF  THE  ABDOMEN,  WITH  EUPTUKE  OF  THE 

INTESTINE. 

BEING  THE  ESSENTIAL  PART  OF  AN  ESSAY  AWARDED  THE  CARTWRIGHT 
PRIZE  OF  THE  ALUMNI  ASSOCIATION  OF  THE  COLLEGE  OF 
PHYSICIANS  AND  SURGEONS,  OF  NEW  YORK. 1 

By  B.  Farquhar  Curtis,  M.D., 

ASSISTANT  SURGEON  TO  THE  NEW  YORK  CANCER  HOSPITAL. 

The  operative  treatment  of  traumatic  peritonitis,  and  of  the  injuries 
which  cause  it,  is  a  matter  of  such  universal  interest  at  present  that  these 
pages  need  no  apology.  By  a  series  of  44  experiments  upon  dogs,  the 
general  subject  of  contusion  of  the  abdomen  with  rupture  of  the  intestine 
has  been  studied.  By  experiments  upon  the  cadaver  it  has  been  sought 
to  throw  some  light  upon  the  still  doubtful  mechanics  of  rupture  of  the 
gut.  An  analysis  of  116  cases  of  rupture  of  the  intestine,  and  of  33  cases 
of  contusion  of  the  abdomen  terminating  in  recovery,  has  been  made, 
with  especial  attention  to  the  symptoms  of  the  first  hours  after  the  injury, 
in  the  hope  of  rendering  an  early  diagnosis  possible.  Finally,  an  attempt 
has  been  made,  in  the  light  of  the  experimental  and  clinical  experience 
thus  far  gained,  to  indicate  the  most  promising  methods  of  treatment. 

I.    Experiments  upon  Dogs. 

The  experiments  on  dogs  were  conducted  upon  the  following  plan  :: 
The  animals  were  put  under  the  influence  of  ether,  laid  upon  the  back 

1  The  original  essay,  containing  a  full  account  of  all  the  experiments,  and  tables,  with  an  analysis  of 
the  cases,  and  references  to  their  source,  has  been  deposited  in  the  library  of  the  New  York  Academy  of 
Medicine. 

2  The  experiments  were  performed  at  the  Carnegie  Laboratory  in  New  York,  and  the  author  is  in- 
debted to  Dr.  G.  B.  Phelps  and  Dr.  F.  A.  Manning  for  most  valuable  assistance  in  the  operations. 

NO.  CLXXXV1II.— OCTOBER,  1887.  21 


322  CURTIS,  RUPTURE   OF   THE  INTESTINE. 

on  the  floor,  and  a  weight  dropped  upon  the  abdomen.  The  weights 
varied  from  six  to  twenty-one  pounds ;  and  the  height  of  the  fall  from 
four  to  seven  feet.    The  striking  surfaces  employed  were  as  follows : 

Surface  A.  The  side  of  a  cylinder  fifteen  inches  long,  and  one  and  a 
half  inches  in  diameter,  the  cylinder  being  dropped  in  a  horizontal  posi- 
tion, its  long  axis  crossing  the  animal's  spine  at  right  angles. 

Surface  B.  A  convex,  circular  surface,  about  two  and  a  half  inches  in 
diameter,  the  greatest  height  of  the  convexity  being  about  half  an  inch. 
For  most  of  these  experiments,  a  common  porcelain  door-knob  formed 
the  striking  surface. 

Surface  C.  A  rectangular  piece  of  wood,  five  by  two  inches,  the  edges 
rounded  off,  leaving  a  flat  surface  in  the  middle,  three  by  one  inches. 
This  was  also  dropped  with  its  long  axis  crossing  the  spine  at  right 
angles. 

After  the  blow  had  been  inflicted,  three  courses  were  pursued.  1.  The 
animal  was  allowed  to  recover  from  the  ether  and  left  to  its  fate.  2. 
Laparotomy  was  performed  after  an  interval  of  twenty-four  hours ;  or  of 
only  five  hours.  3.  Laparotomy  was  done  at  once — the  most  usual 
course. 

The  immediate  symptoms  produced  by  the  blow  were  trifling.  Shock 
appeared  in  about  one-half  the  cases,  but  it  was  usually  slight.  It  was 
present  in  three  of  the  cases  in  which  no  injury  was  sustained,  and  was 
severe  in  one  of  these,  so  that  it  was  no  indication  of  the  severity  of  the 
injury  received.  When  severe,  it  was  generally  a  sign  of  great  hemor- 
rhage, or  was  due  to  the  fact  that  the  animal  was  not  entirely  under  the 
influence  of  the  ether. 

In  ten  cases  no  injury  was  produced — in  three  of  these  nothing  further 
was  done,  the  intention  being  to  wait  for  symptoms ;  in  the  others  lapa- 
rotomy was  performed  at  once  for  exploration. 

In  the  dog  the  caecum  lies  by  the  side  of  the  last  part  of  the  ileum,, 
deriving  its  blood  supply  from  a  branch  of  the  mesenteric  artery  which 
runs  in  the  cellular  tissue  between  the  two.  In  two  cases  the  caecum  wa& 
separated  from  this  attachment  to  the  ileum,  rupturing  the  branches  of 
this  vessel,  the  main  trunk  being  left  attached  to  the  small  intestine. 
This  artery  was  of  such  large  size  that  in  one  of  these  cases  four  ounces 
of  blood  were  lost  from  it  in  the  few  minutes  elapsing  before  the  belly 
was  opened.  In  both  cases  gangrene  of  the  caecum  was  inevitable,  and 
that  part  was  resected,  both  animals  recovering. 

Laceration  of  the  mesentery,  so  severe  as  to  deprive  part  of  the  intes- 
tine of  its  blood  supply,  occurred  in  thirteen  cases,  and  was  treated  by 
immediate  laparotomy,  except  in  one  case  w7hich  died  of  hemorrhage 
half  an  hour  after  the  injury.  Four  others  died  on  the  table  of  hemor- 
rhage. An  artificial  anus  was  made  three  times  and  the  intestine  re- 
sected five  times — but  all  died  within  twelve  hours  of  hemorrhage  and 


CUKTIS,  RUPTURE    OF   THE  INTESTINE. 


32-3 


shock,  except  one  of  the  resection  cases,  which  lived  for  forty-eight  hours, 
dying  of  peritonitis  from  silk  which  was  not  aseptic.  The  unfortunate 
results  of  the  cases  of  artificial  anus  led  to  frequent  attempts  at  resection, 
although  the  animal  was  too  feeble  to  warrant  it,  and  death  was  caused 
by  the  shock  and  exhaustion  due  to  the  prolonged  operation. 

In  addition  to  these  cases  of  laceration  of  the  mesentery  necessitating 
resection,  there  was  one  case  in  which  a  large  branch  of  the  mesenteric 
artery  was  injured,  with  such  a  profuse  hemorrhage  that  life  was  endan- 
gered. The  vessel  was  secured  by  ligature,  the  collateral  circulation  of 
the  corresponding  part  of  the  gut  found  sufficient,  and  the  animal  made 
a  good  recovery. 

Contusion  of  the  intestine  severe  enough  to  require  treatment  occurred 
in  ten  cases,  including  those  cases  in  which  the  ecchymosis  was  so  exten- 
sive as  to  threaten  perforation  of  the  gut,  most  of  them  being  also  accom- 
panied by  a  laceration  of  some  of  the  coats  of  the  intestine.  The  usual 
form  of  this  last  injury  was  a  small  fissure  in  the  peritoneal  and  muscular 
coats  exposing  the  fibrous  coat.  It  must  be  remembered  that  in  the  dog 
the  submucous  coat  of  the  intestine  is  developed  into  a  strong  fibrous 
tissue  resembling  a  thin  aponeurosis,  making  the  wall  of  the  gut  very 
much  stronger  than  in  man.  Even  if  the  fissure  was  small,  the  edges 
were  so  bruised  and  ragged  that  the  fibrous  coat,  although  itself  unin- 
jured, was  deprived  of  all  blood  supply,  except  the  minute  vessels  which 
lay  in  its  own  tissue,  between  it  and  the  mucous  membrane,  or  in  the 
tissue  of  the  latter.  In  injuries  of  this  kind  the  mucous  membrane  was 
found  entirely  destroyed  by  the  blow,  or  separated  from  the  underlying 
fibrous  coat  by  effusion  of  blood,  so  that  there  was  no  possibility  of  its 
capillaries  supplying  the  latter  with  blood  even  if  they  are  normally 
equal  to  the  task — which  seems  doubtful. 

In  four  cases  the  injured  point  was  turned  into  the  lumen  of  the  gut 
and  sutured,  and  three  of  these  recovered,  the  fourth  dying  of  intestinal 
obstruction,  caused  by  a  Z-shaped  bend  in  the  gut  at  the  point  of  suture, 
held  by  firm  adhesions.  Six  cases  were  treated  by  resection,  of  which 
two  recovered.  The  others  died — one  of  shock,  two  by  yielding  of  the 
sutures  at  the  point  of  resection,  and  one  of  peritonitis  caused  by  silk 
which  was  not  aseptic.  Thus  we  have  in  this  set  of  cases  a  total  of  five 
recoveries  and  five  deaths. 

One  of  the  later  experiments  illustrated  the  necessity  for  these  pre- 
cautions in  a  very  striking  way. 

In  this  case  (a  dog  which  had  been  already  subjected  to  a  resection  ex- 
periment) the  weight  was  dropped  and  laparotomy  was  performed  five  hours 
later.  The  intestine  was  found  ruptured  entirely  across  at  a  point  in  the  duo- 
denum, and  a  loop  which  had  been  adherent  to  the  inner  surface  of  the  former 
abdominal  wound  had  been  forcibly  separated  from  its  adhesions,  thus  tearing 
off  its  peritoneal  and  the  greater  part  of  its  muscular  coat  for  a  space  of  about 
one  inch  square,  but  not  laying  the  fibrous  coat  entirely  bare.    The  dog  vras 


324 


CURTIS,   RUPTURE   OF   THE  INTESTINE. 


so  feeble  by  the  time  that  the  ruptured  point  had  been  sutured,  that  it  was 
determined  to  leave  this  doubtful  place  to  nature — the  rather  because  there  had 
been  no  contusion  at  this  point,  the  injury  having  been  caused  by  a  dragging 
and  stripping  off  of  the  superficial  parts,  and  there  seemed  good  reason  to  sup- 
pose that  the  mucous  membrane  was  intact,  and  that  its  vessels  would  suffice 
to  supply  the  fibrous  coat  with  blood.  The  dog  died  of  shock  about  eight 
hours  after  the  operation,  and  we  found  that  the  doubtful  spot  was  black  and 
completely  gangrenous.  ' 

Rupture  of  the  intestine  was  produced  in  eight  cases,  in  two  of  which 
there  were  two  ruptures.  Of  these  ten  ruptures  of  the  gut,  four  extended 
completely  across  it,  and  two  almost  across.  Of  the  rest,  three  were 
directed  in  the  long  axis  of  the  gut,  while  only  one  was  transverse — all 
four  being  situated  on  the  free  border.  One  of  the  two  cases  which  ex- 
tended almost  across  the  gut  involved  all  but  the  attached  border,  the 
other  all  but  the  free  border — the  latter  a  very  rare  form  of  the  injury. 

The  mucous  membrane  was  generally  everted,  but  not  in  all  cases — 
depending  upon  the  amount  of  contusion  which  the  edges  of  the  opening 
had  suffered.  In  some  cases,  in  which  laparotomy  was  done  at  once,  the 
edges  were  found  much  less  everted  at  first  than  they  subsequently  be- 
came, for  the  muscular  contraction  which  causes  the  eversion  occurs 
slowly,  and  the  muscular  tissue  may  have  been  partially  paralyzed  by 
the  blow.  This  gives  another  proof  of  how  little  eversion  of  the  mucous 
membrane  is  to  be  depended  upon  to  prevent  fecal  extravasation.  In 
the  complete  ruptures  the  ends  were  partly  closed  by  muscular  contrac- 
tion. The  same  contraction  caused  wide  gaping  of  the  ruptures  which 
were  directed  in  the  long  axis  of  the  gut. 

Rupture  of  the  intestine  was  treated  in  one  case  by  resection  with 
suture  of  the  gut  five  hours  after  the  injury.  The  dog  died  of  shock 
and  beginning  septicaemia  and  peritonitis,  within  twelve  hours.  It  was 
treated  by  immediate  laparotomy  in  four  cases.  One  of  these  died  from 
hemorrhage  within  one  hour  after  the  injury,  there  being  a  laceration  of 
the  mesentery  also.  Two  were  too  severely  injured  to  permit  resection 
and  suture,  and  an  artificial  anus  was  made.  One  of  these  died  of  shock ; 
the  other  recovered  from  the  operation  but  succumbed  to  purulent  peri- 
tonitis starting  from  the  abdominal  wound.  The  remaining  case  had  a 
rupture  wrhich  admitted  of  suture,  as  it  did  not  extend  entirely  across 
the  gut,  and  recovered. 

The  most  troublesome  part  of  suture  of  the  intestine  in  resection  is 
the  introduction  of  the  stitches  at  the  mesenteric  border,  on  account  of 
the  difficulty  of  bringing  the  serous  surfaces  in  contact  at  this  point. 
The  triangular  interval  between  the  two  layers  of  the  mesentery  at  its 
attachment  to  the  gut  cannot  be  much  reduced  by  the  lateral  pressure 
of  two  Lembert  sutures,  placed  one  on  each  side  of  the  mesentery  in  the 
usual  way.  A  small  raw  surface,  the  cut  edge  of  the  mesentery,  will 
always  remain,  communicating  at  one  end  with  the  interior  of  the  gut, 


CURTIS,  RUPTURE   OF   THE  INTESTINE. 


325 


and  at  the  other  with  the  peritoneal  cavity.  It  occurred  to  me  that  if 
the  mesentery  could  be  folded  down  upon  the  outside  of  the  intestine, 
and  then  turned  in  with  the  latter  at  the  point  of  suture,  this  raw  sur- 
face would  be  reduced  to  a  minimum. 

To  secure  this  by  sutures,  they  should  be  passed  in  the  following  man- 
ner: Let  the  cut  end  of  intestine  nearest  the  operator's  right  hand  hang 
free  from  its  mesentery.  Pass  the  needle  through  the  mesentery  at  a 
point  one-third  of  an  inch  from  the  free  edge  of  the  mesentery  and  one- 
quarter  of  an  inch  from  its  attachment  to  the  gut.  Taking  up  the 
needle  on  the  further  side  of  the  mesentery,  make  a  Lembert  stitch  on 
the  surface  of  the  intestine  on  that  side,  entering  the  needle  one-third  of 
an  inch  from  the  cut  edge  of  the  gut  and  one-quarter  of  an  inch  from 
the  attachment  of  the  mesentery  to  the  gut,  and  keeping  it  parallel  with 
the  mesenteric  attachment,  bring  it  out  near  the  cut  edge  of  the  gut  in 
the  ordinary  way  (Fig.  1).   Then  pass  the  needle  back  again  through 


Fig.  1. 


the  mesentery  at  a  point  one-quarter  of  an  inch  from  its  attachment  to 
the  intestine,  but  near  its  cut  edge,  so  that  the  needle  will  finish  upon 
the  same  side  of  the  mesentery  as  it  started  from.  If  the  thread  is  now 
drawn  tight,  it  will  be  seen  that  the  mesentery  is  folded  down  upon  the 
side  of  the  gut  by  the  thread. 

Now  hold  up  the  other  end  of  intestine  by  its  mesentery,  the  edge 
directed  toward  the  first,  as  it  is  intended  to  unite  them.  Pass  the 
needle  through  the  mesentery  of  this  second  end  of  gut  near  its  cut  edge 
and  one-quarter  of  an  inch  from  its  attachment  to  the  intestine.  Taking 
up  the  needle  on  the  further  side  of  the  mesentery,  make  a  Lembert 
stitch  on  the  surface  of  the  intestine  on  that  side,  entering  the  needle 
near  the  cut  edge  of  gut  at  a  point  one-quarter  of  an  inch  from  the 
attachment  of  the  mesentery,  and  bringing  it  out  one-third  of  an  inch 
from  the  cut  edge  of  the  gut  and  one-quarter  of  an  inch  from  the  mesen- 
teric attachment  (Fig.  2).  The  needle  is  then  to  be  passed  back  again 
through  the  mesentery  at  a  point  one-quarter  of  an  inch  from  its  attach- 
ment to  the  intestine  and  one-third  of  an  inch  from  its  cut  edge  (Fig.  3  I. 


326 


CURTIS,  RUPTURE    OF   THE  INTESTINE. 


The  completed  stitch  is  exactly  the  same  on  both  ends  of  the  gut, 
although  the  course  of  the  needle  on  the  second  end  was  just  the  reverse 
of  that  taken  on  the  first. 

It  will  then  be  seen  that  the  two  Lembert  sutures  are  on  the  same 
(further)  side  of  the  mesentery,  and  parallel  to  its  attachment  to  the 


Fig.  2. 


intestine.  If  the  ends  of  the  thread  are  drawn  upon,  it  will  be  found 
that  the  mesentery  of  both  ends  of  the  gut  is  folded  down  upon  the  sides 
of  the  intestine.  If  they  are  drawn  still  tighter,  the  ends  of  the  gut  will 
be  turned  in  (in  the  usual  way  with  the  Lembert  suture),  and  carry  the 
edges  of  the  down-folded  mesentery  with  them,  and  a  knot  can  be  made 
in  the  ordinary  manner. 

We  have  thus  succeeded  in  disposing  of  the  thickest  part  of  the 
mesentery  by  turning  it  into  the  lumen  of  the  intestine,  just  as  the  raw 
edges  of  the  gut  itself  are  turned  in.    At  a  distance  of  one-quarter  of  an 


Fig.  3. 


inch  from  the  mesenteric  attachment  the  loose  cellular  tissue  which  tills 
the  triangular  space  between  the  layers  of  the  mesentery  close  to  the 
gut  is  much  reduced  in  quantity,  if  not  altogether  absent ;  and  when  the 
mesentery  has  been  turned  down  upon  the  side  of  the  intestine  as 
described  above,  this  thin  part  of  the  mesentery  is  the  part  which  will 


CURTIS,  RUPTURE   OF   THE   INTESTINE.  327 


find  its  way  out  -of  the  seam  when  the  ends  of  the  gut  are  turned  in. 
This  is  far  less  likely  to  interfere  with  prompt  union  than  the  compara- 
tively broad  surfaces  brought  together  by  the  sutures  as  usually  applied. 
This  stitch  is  much  more  complicated  in  its  description  than  in  its  appli- 
cation, although  it  cannot  be  denied  that  the  latter  is  also  difficult. 
But  the  much  greater  security  which  it  affords  has  proven  it  to  be  well 
worth  the  additional  trouble  in  the  numerous  cases  in  which  it  has  been 
used. 

Having  applied  this  stitch,  two  Lembert  sutures  should  be  inserted 
close  to  it,  one  on  each  side.  One  of  these  has  to  pass  through  the  place 
where  the  mesentery  is  folded  over,  making  several  thicknesses  with 
considerable  cellular  tissue,  and  the  needle  must  be  made  to  pass  a  little 
deeper  than  usual  in  order  to  take  up  the  muscular  coat,  otherwise  it 
will  tear  out  very  easily. 

The  following  conclusions  are  justified  by  the  facts  already  presented : 

1.  Exploratory  laparotomy  can  be  performed  without  danger. 

2.  The  most  common  causes  of  death  after  contusion  of  the  abdomen, 
produced  as  described,  are  hemorrhage  and  shock;  and  the  latter  is 
greatly  increased  by  a  prolonged  operation,  such  as  resection  of  the 
intestine. 

3.  Some  cases  of  internal  hemorrhage,  otherwise  fatal,  can  be  saved 
by  prompt  action. 

4.  Prompt  action  will  save  life  in  contusion,  threatened  gangrene,  and 
even  rupture  of  the  intestine. 

5.  The  danger  is  greatly  increased  by  delay,  as  shown  by  the  early 
occurrence  of  gangrene,  the  rapid  failure  and  death  of  cases  left  without 
treatment,  and  the  greatly  impaired  strength  found  in  cases  in  which 
treatment  was  delayed. 

II.  Experiments  upon  the  Cadaver. 

There  are  two  theories  in  regard  to  the  mechanical  causation  of  rup- 
ture of  the  intestine  by  contusion  of  the  abdomen — that  it  is  caused  by 
a  blow  inflicted  upon  the  gut  distended  with  gas  or  with  fluid  contents ; 
and  that  it  is  caused  by  the  crushing  of  the  gut,  whether  distended  or 
empty,  between  the  contusing  body  and  some  hard  background,  usually 
the  spinal  column.  Longuet1  dropped  a  weight  upon  the  bodies  of  three 
cadavers,  alternately  over  the  spine  and  to  one  side  of  it.  In  order  to 
gain  additional  evidence,  I  have  repeated  his  experiments  upon  four 
cadavers.2 

Including  both  series  of  experiments,  we  obtain  a  total  of  five  blows 
delivered  in  the  middle  line,  causing  in  three  a  rupture  of  the  gut,  and 

1  Bull.  Soc.  Anat.,  Paris,  1875,  1.  p.  799. 

2  The  author  is  indebted  to  Dr.  George  L.  Peabody,  Pathologist  to  the  New  York  Hospital,  tor  the 
opportunity  to  experiment  upon  the  cadaver. 


328 


CUETIS,  RUPTURE   OF   THE  INTESTINE. 


in  the  other  two  a  laceration  of  the  mesentery.  On  the  other  hand,  of 
nine  blows  delivered  laterally,  in  six  cases  there  was  no  injury;  and  in 
the  three  in  which  injury  was  caused,  the  weight  touched  the  side  of  the 
spine  in  its  fall,  but  in  none  of  these  three  was  a  rupture  of  the  gut  pro- 
duced. Thus,  in  a  total  of  fourteen  blows,  the  eight  which  struck  the 
spine  produced  injuries,  and  the  six  which  did  not  touch  it  were  harmless. 

This  evidence  proves  conclusively  that  distention  of  the  intestine  is 
not  necessary  for  rupture,  but  that  a  contact  between  the  contusing  body 
and  some  solid  resistance,  such  as  would  be  furnished  by  the  spine  or 
the  pelvic  bones,  is  indispensable  to  produce  rupture  in  the  empty  gut. 
But  there  is  still  some  footing  left  for  the  old  theory.  Can  a  distended 
loop  of  gut  be  ruptured  when  it  lies  upon  one  side  of  the  spine,  where 
we  have  proven  the  collapsed  gut  to  be  safe  from  injury?  To  determine 
this  point,  the  following  experiments  were  performed: 

An  incision  about  three  inches  long  was  made  in  the  middle  line  of 
the  belly,  the  lower  end  of  the  incision  being  placed  at  the  pubes.  One 
or  more  loops  of  gut  were  drawn  out,  inflated  with  air  after  isolation 
between  two  ligatures,  returned  to  the  belly,  and  placed  either  over  the 
spine  above  the  incision  or  upon  one  side  of  it,  in  the  lumbar  region. 
The  incision  was  closed  by  suture,  and  the  weight  dropped  directly  over 
the  prepared  loops.  This  experiment  was  carried  out  upon  five 
cadavers. 

In  this  set  of  experiments,  of  four  blows  delivered  upon  loops  lying 
in  the  middle  line,  in  front  of  the  vertebra?,  rupture  of  the  gut  was  pro- 
duced twice,  and  rupture  of  its  peritoneal  coat  in  the  other  two  cases,  in 
one  of  which  there  was  also  produced  a  laceration  of  the  mesentery. 
This  last  experiment  shows  how  readily  the  inflated  gut  may  escape  rup- 
ture, for  the  descending  weight  could  only  have  reached  the  mesentery 
by  pushing  aside  the  intestine,  which  lay  in  front  of  it.  One  of  these 
experiments  shows  that  the  inflated  gut  may  even  prevent  injury  to  other 
structures,  for  it  is  the  only  experiment  of  all  performed  by  Longuet 
and  myself  in  which  a  direct  blow  upon  the  spine  failed  to  produce  some 
injury,  for  rupture  of  the  peritoneal  coat  can  scarcely  be  considered  an 
injury.  We  must,  therefore,  acknowledge  that  inflation  of  the  gut  does 
not  increase  the  danger  of  rupture  in  loops  lying  against  the  spine,  and 
may  even  diminish  it. 

On  the  other  hand,  of  seven  blows  delivered  upon  loops  placed  at  the 
side  of  the  spine,  in  only  three  was  no  injury  produced,  while  rupture  of 
the  gut  occurred  three  times,  and  rupture  of  its  peritoneal  coat  once. 

We  may  conclude  chat — 

1.  In  contusion  of  the  abdomen  the  intestine  is  ruptured  by  being 
crushed  between  the  contusing  body  and  the  bony  parts — the  vertebra? 
and  pelvis.  This  injury  is  therefore  not  a  true  rupture,  but  a  contused 
and  lacerated  wound  of  the  gut. 


CURTIS,  RUPTURE   OF   THE  INTESTINE. 


829 


2.  Partial  distention  of  the  gut,  especially  if  a  large  part  of  the  intes- 
tine is  distended,  diminishes  the  danger  of  rupture.  If  great  distention 
of  an  isolated  loop  ever  occurred  in  life,  it  would  increase  the  danger  of 
rupture,  even  for  a  loop  not  in  contact  with  bony  parts. 

3.  The  most  exposed  position  for  the  gut  is  in  contact  with  the  bony 
parts — in  front  of  the  vertebrae,  near  the  brim  of  the  pelvis  (when  hernia 
is  present),  and  near  the  crest  of  the  ilium. 

4.  There  are  many  chances  in  favor  of  escape  of  the  intestine  from 
injury  in  contusion  of  the  abdomen — there  may  be  no  gut  lying  directly 
at  the  point  where  the  blow  is  inflicted;  the  gut  may  be  partially  inflated 
with  gas;  or  it  may  slip  away  from  the  pressure  exercised  by  the  blow. 
This  fact  is  of  great  importance  in  its  bearing  upon  the  question  of  early 
performance  of  laparotomy  for  rupture  of  the  intestine. 

III.  Clinical. 

Pathology. — 116  cases  of  rupture  of  the  intestine  have  been  collected 
with  the  intention  of  studying  the  symptoms  of  the  first  six  to  twelve 
hours  after  the  accident,  only  those  cases  in  which  these  symptoms  were 
described  with  sufficient  fulness  being  accepted.  A  few  exceptions  were 
made  to  this  rule  in  order  to  secure  examples  of  rare  symptoms,  or  of 
rare  forms  of  injury,  and  thus  the  proportion  of  these  unusual  cases  is 
greater  than  would  be  found  in  a  consecutive  series  of  cases,  and  due 
allowance  must  be  made  for  this  fact  in  certain  points  which  will  be 
hereafter  pointed  out. 

The  cause  of  the  injury  is  described  in  99  cases.  The  most  common 
cause  is  the  kick  of  a  horse  or  man,  numbering  together  28  cases— 
twice  as  many  as  are  due  to  any  other  cause.  Next  to  this,  and  all 
nearly  equal  in  the  number  of  cases,  are  the  run-over  accidents  (13 
cases),  the  blows  on  the  belly  by  heavy  weights  (16)  and  by  light  weights 
(13),  and  the  falls  upon  projecting  points  (13).  The  so-called  "buffer 
accidents"  are  comparatively  rare  (4  cases).  It  is  evident  that  the 
great  velocity  and  small  area  of  striking  surfaces  are  the  elements  which 
make  a  kick  so  dangerous. 

The  relative  frequency  of  injury  in  different  parts  of  the  intestine  is 
shown  by  the  following :  in  113  cases,  the  duodenum  was  injured  6  times, 
the  jejunum  44,  the  ileum  38,  other  portions  of  the  small  intestine  21 
times,  and  the  large  intestine  only  4  times.  This  proportion  indicates  that 
the  liability  of  the  jejunum  to  injury  is  no  greater  than  that  of  the  ileum. 
The  duodenum  escapes  on  account  of  its  sheltered  position.  In  43  cases 
the  exact  site  of  the  rupture  is  given  in  the  jejunum  and  ileum,  and  in 
25  (58  per  cent )  of  these  it  lay  in  the  first  three  feet  of  the  jejunum,  or 
in  the  last  three  feet  of  the  ileum.  In  12  cases  (28  per  cent.)  the  rup- 
ture was  situated  in  the  first  eighteen  inches  of  the  jejunum,  and  in  (> 
(14  per  cent.)  in  the  last  eighteen  inches  of  the  ileum.    These  facts  boar 


380 


CURTIS,  RUPTURE   OF   THE   INTESTINE  . 


out  the  old  theory  that  the  danger  of  rupture  is  greatest  in  those  parts 
of  the  intestine  which  are  most  fixed  in  their  position  in  the  abdomen, 
but  the  large  intestine  must  be  excepted  on  account  of  its  sheltered 
position. 

Of  the  entire  116  cases  the  rupture  extended  completely  across  the 
intestine  in  20  cases,  and  almost  across  in  4.  In  11  cases  there  were 
multiple  ruptures,  in  2  of  these  there  were  four  ruptures,  in  2  there  were 
three,  and  in  3  two.  In  only  two  of  the  cases  in  which  the  rupture 
extended  part- way  across  the  intestine  is  it  mentioned  that  the  mesenteric 
border  alone  was  involved.  In  only  one  case1  was  the  rupture  so  situated 
as  not  to  communicate  with  the  peritoneal  cavity,  and  then  it  lay  on  the 
posterior  wall  of  the  duodenum  where  it  passes  behind  the  mesentery. 

The  rupture  varies  from  the  size  of  a  quill  to  one  which  will  admit 
four  fingers,  but  is  most  frequently  about  one  inch  in  diameter.  Is  there 
any  constant  relation  between  the  force  of  the  blow  and  the  extent  of 
the  rupture?  A  study  of  the  twenty  cases  in  which  the  rupture  was 
complete,  shows  that  the  blow  was  severe  in  all  but  two.  On  the  other 
hand,  among  the  causes  of  the  twenty-two  cases  in  which  the  rupture 
was  half  an  inch  or  less  in  extent,  there  are  only  three  in  which  the 
blow  appears  to  have  been  severe.  These  cases  warrant  the  assertion 
that  the  amount  of  injury  will  be  proportional  to  the  violence  of  the 
blow,  but  that  exceptions  will  not  be  infrequent.  A  small  rupture, 
however,  is  almost  as  certain  to  prove  fatal  as  a  large  one,  so  the  ques- 
tion has  very  little  practical  importance.  A  striking  instance  of  this  is 
a  case2  in  which  the  rupture  was  only  one-third  of  an  inch  in  diameter 
and  yet  death  occurred  in  sixteen  hours. 

E version  of  the  mucous  membrane  at  the  injured  point  is  the  rule, 
being  mentioned  as  present  in  ten  partial,  and  four  complete  ruptures, 
while  it  is  noted  as  absent  in  only  two  cases.  Jukes  also  records  a  case8 
in  which  there  was  an  extensive  lesion  of  the  peritoneal  coat,  with  a 
rupture  of  the  bowel  the  size  of  a  goose-quill,  with  no  eversion  of  the 
mucous  membrane — fecal  extravasation  and  peritonitis  were  present 
and  death  had  occurred  forty  hours  after  the  accident.  In  one  of  our 
cases4  the  mucous  membrane  rolled  out  and  the  peritoneum  turned  in, 
the  two  covering  the  cut  edge  of  the  muscular  coat. 

Fecal  extravasation  is  almost  invariably  present,  but  may  be  delayed, 
or  even  absent.  It  is  recorded  as  present  in  seventy-three  cases,  but  the 
presence  of  peritonitis  in  nearly  all  the  rest  makes  it  probable  that  it 
was  present  in  them  also,  although  peritonitis  may  possibly  arise  from 
other  causes  than  fecal  extravasation.    In  nine  cases  it  is  recorded  as 

1  Gartner:  Vierteljahrschrift  f.  prakt.  Heilk.,  Prag,  1854,  xlii  p.  44. 
-  Annan  :  American  Journal  of  the  Medical  Sciences,  xxi.  p.  530,  1837. 

3  Jukes  :  Med.  Ckir.  Journ.  and  Rev.,  v.  p.  269,1818. 

4  Cbavignez  :  Bull.  Soc.  Anat.,  Paris,  1839,  xiv.  p.  217. 


CURTIS,  RUPTURE   OF   THE  INTESTINE. 


331 


absent.  In  some  of  these  cases  peritonitis  was  present,  but  they  show 
that  it  is  not  impossible  for  fecal  extravasation  to  be  wanting.  In  two 
cases1  of  complete  rupture,  the  open  ends  were  so  entirely  closed  by 
muscular  contraction,  prolapse  of  the  mucous  membrane,  and  rapidly 
formed  adhesions,  that  the  bowel  was  actually  found  to  be  distended 
above  the  injured  point.  In  such  a  case  it  is  easy  to  understand  how 
fecal  extravasation  could  be  prevented — and,  in  fact,  in  one  of  these 
cases  the  onset  of  symptoms  was  delayed.  This  condition  would  be 
more  likely  to  occur  with  complete  ruptures  than  with  partial — unless 
the  latter  were  very  small,  just  as  hemorrhage  is  more  severe  when  an 
artery  is  wounded  in  part  of  its  circumference  than  when  it  has  been 
entirely  divided  and  the  injured  end.  is  free  to  contract  and  retract.  The 
phenomena  observed  in  the  experiments  upon  dogs  as  to  the  contraction 
of  the  intestinal  muscle  furnish  excellent  illustrations  of  this  subject. 

With  rupture  of  the  intestine  were  found  in  twelve  cases  contusions 
and  other  slight  injuries  of  the  gut.  Contusion  of  the  gut  may  lead  to 
peritonitis  even  when  not  so  severe  as  to  cause  gangrene  and  perforation, 
as  has  also  been  shown  by  Grawitz,2  the  diminished  vitality  of  the  tissues 
allowing  microorganisms  to  penetrate  them  and  set  up  inflammation  in 
the  adjacent  peritoneum.  Similar  conditions  are  seen  in  practice,  in  the 
peritonitis  accompanying  intestinal  obstruction,  or  following  the  reduc- 
tion of  a  strangulated  hernia. 

The  most  frequent  and  important  complication  of  rupture  of  the  intes- 
tine is  laceration  or  contusion  of  the  mesentery.  The  hemorrhage  from 
the  ruptured  gut  is  trifling  unless  the  mesenteric  border  is  involved,  and 
even  then  it  is  not  usually  serious.  But  hemorrhage  from  laceration  of 
the  mesentery  may  cause  death  in  a  few  minutes,  and  even  slight  injury 
to  its  vessels  may  deprive  part  of  the  intestine  of  its  blood  supply,  and 
cause  gangrene,  although  the  gut  itself  have  escaped  injury.  There  are 
four  cases  of  contusion,  and  fifteen  of  laceration  of  the  mesentery,  com- 
plicating the  cases  of  rupture  of  the  intestine.  Of  the  last  set  of  cases 
all  but  three  of  the  patients  died  within  twenty-four  hours,  and  in  these 
three  no  mention  is  made  as  to  the  state  of  the  circulation  in  the  gut  at 
the  time  of  death.  In  some  of  those  in  which  death  occurred  early, 
gangrene  of  portions  of  the  gut  was  inevitable ;  and  in  a  case  in  which 
laceration  of  the  mesentery  was  the  only  injury,  it  was  found  that  gan- 
grene had  already  taken  place  at  the  time  of  death.  The  frequency  and 
gravity  of  this  complication  of  rupture  of  the  intestine  does  not  seem  to 
be  properly  appreciated.  It  occurred  in  sixteen  per  cent,  of  the  cases 
collected,  and  we  have  already  seen  how  often  it  was  produced  in  the 
experiments  on  dogs.    Probably  the  smaller  lacerations  (competent, 

1  Partridge:  Trans.  Path.  Soc,  London,  I8i>0-1,  xii.  p.  109.  Poland:  Med.  Times  and  Ga/..,  ii.  p. 
445,  1868. 

1  Charite-Annalen,  xi.  Jahrg.,  p  770,  Berlin. 


332 


CUKTIS,  RUPTURE   OF   THE  INTESTINE. 


however,  to  produce  gangrene)  are  frequently  overlooked  in  the  autopsies 
made  in  cases  of  contusion  of  the  abdomen  dying  in  the  first  twenty-four 
hours,  and  many  such  cases  with  symptoms  of  severe  internal  hemor- 
rhage are  allowed  to  pass  without  autopsy  on  a  diagnosis  of  rupture  of 
the  liver  or  spleen,  in  which  the  real  lesion  is  a  laceration  of  the  mesen- 
teric vessels,  with  or  without  injury  to  the  intestine. 

Symptoms  of  the  Early  Stage.  —  The  symptoms  immediately 
following  the  injury  are  of  the  greatest  importance,  for  the  diagnosis 
must  be  made  as  soon  as  possible,  if  the  treatment  is  to  be  successful. 

These  symptoms  are  shock,  with  or  without  loss  of  consciousness, 
restlessness,  vomiting,  retention  of  urine,  absence  of  fecal  passages,  local 
pain  and  tenderness,  and  the  physical  signs  afforded  by  examination  of 
the  abdomen.  The  condition  of  the  pulse  at  this  time  will  not  need 
separate  consideration,  as  it  depends  upon  the  amount  of  shock,  and 
hemorrhage,  and  often  does  not  assist  even  in  a  distinction  between 
these.  The  temperature  is  of  little  value  as  a  guide,  although  it  is  some- 
times subnormal  when  the  shock  is  great,  and  may  rise  as  peritonitis 
develops. 

The  symptoms  may  all  appear  immediately  upou  receipt  of  the  injury, 
or  one  or  all  may  be  delayed  for  some  hours.  Delay  in  the  appearance 
of  symptoms  was  present  in  ten  cases,  and  some  are  so  remarkable  as  to 
deserve  a  fuller  account. 

A  boy,1  thirteen  years  old,  received  a  blow  upon  the  abdomen  from  the  pole 
of  a  churning  machine,  walked  a  mile  with  but  little  assistance,  had  great 
pain  and  vomited  frequently  and  persistently,  but  the  symptoms  were  "not  at 
all  marked."  In  twelve  hours  sudden  collapse  came  on,  and  death  followed 
one  hour  later.    Autopsy  showed  a  complete  rupture  of  the  duodenum. 

A  man,2  nineteen  years  old,  fell  from  his  cart  while  drunk,  and  the  wheel 
passed  over  his  body.  He  was  insensible  from  drink,  and  vomited  the  con- 
tents of  his  stomach,  but  there  was  no  shock  and  no  other  symptoms.  The 
next  day  he  felt  well,  there  was  no  tenderness  in  the  abdomen,  and  the  urine 
and  stool  were  passed  normally.  He  was  allowed  to  walk  about  the  ward  of 
the  hospital,  and  to  eat  three  meals  of  bread,  broth,  and  milk.  Twenty-six 
hours  after  the  accident,  and  half  an  hour  after  the  last  meal,  sudden  cramp- 
ing pains  in  the  abdomen  came  on,  collapse  followed,  and  death  in  one  hour 
and  a  half.    Autopsy  showed  a  complete  rupture  of  the  jejunum. 

A  strumous  girl,3  eleven  years  old,  in  running  up  stairs,  fell  and  struck  her 
abdomen,  at  the  level  of  the  umbilicus,  on  the  edge  of  a  step.  She  cried  a 
little,  but  walked  up  stairs,  then  vomited  the  contents  of  her  stomach,  fell 
asleep  and  slept  half  an  hour.  She  seemed  a  little  faint,  and  was  kept  in  bed, 
but  she  felt  well  and  had  no  pain.  She  slept  well  all  that  night.  Twenty 
hours  after  the  accident  she  walked  down  stairs,  after  which  she  felt  slight 
pain  in  the  abdomen  for  awhile,  and  there  was  some  tenderness.  Four  hours 
later  she  ate  a  few  mouthfuls  of  egg-pudding,  the  first  food  she  had  taken 
since  the  accident,  vomited  it,  fell  into  collapse,  and  died  at  once.  Autopsy 
showed  a  rupture  of  the  jejunum  extending  for  half  of  its  circumference  (the 
edges  bruised,  the  mucous  membrane  appearing  as  if  it  had  not  been  everted), 
fecal  extravasation,  and  beginning  peritonitis. 

i  London  Medical  Gazette,  1833,  xii.  p.  766.  2  Walker:  Lancet,  1881,  ii.  p.  657. 

s  Holland  :  British  Medical  Journal,  1873,  i.  p.  703. 


CURTIS,  RUPTURE   OF   THE  INTESTINE. 


333 


The  proportion  of  these  cases  to  the  entire  number  in  the  table  is  mis- 
leading, for  such  peculiar  cases  are  much  more  likely  to  secure  publica- 
tion than  those  which  run  the  ordinary  course.  The  true  proportion 
must  be  far  less  than  one  in  eleven. 

Shock.  In  95  of  the  cases  the  presence  or  absence  of  shock  is  noted. 
Shock  was  present  in  76  cases — 80  per  cent. ;  and  absent  in  19  cases — 
20  per  cent.  It  is  described  as  severe  in  30  cases,  and  as  slight  in  16 
cases. 

Consciousness.  Consciousness  was  retained  at  the  time  of  the  accident 
in  54  cases,  was  almost  lost  in  4  cases,  and  was  lost  in  11  cases.  But 
four  of  the  cases  in  which  it  was  lost  lived  two,  four,  and  seven  days,  and 
the  symptom  is  altogether  unreliable  as  an  indication  of  the  severity  of 
the  injury,  and  even  of  the  degree  of  shock  present. 

Restlessness.  Restlessness  is  not  a  common  symptom.  It  is  noted  as 
present  in  the  early  stage  in  eight  cases ;  while  it  appeared  in  one  case 
after  six  hours,  in  one  case  after  twelve  hours,  and  in  twTo  cases  on  the 
third  day.  The  last  two  cases' do  not  properly  belong  here,  but  they 
are  quoted  to  show  that  restlessness  is  not  exclusively  a  symptom  of 
internal  hemorrhage.  In  these  cases  it  is  doubtless  to  be  regarded  as 
due  to  the  peritonitis — perhaps  merely  as  an  unusual  symptom  of  the 
accompanying  fever.  In  two  of  the  cases  there  was  no  hemorrhage,  and 
in  two  it  was  slight,  and  yet  this  symptom  was  present  from  the  first.  In 
these  cases  restlessness  must  be  regarded  as  part  of  the  symptom-complex 
of  shock. 

Vomiting.  Data  as  to  this  symptom  in  the  early  stage  are  given 
in  90  cases.  Vomiting  was  present  in  72  cases — 80  per  cent. ;  and 
absent  in  18  cases — 20  per  cent.  There  was  nausea  in  four  of  the  cases 
in  which  there  was  no  vomiting,  and  in  most  of  them  vomiting  appeared 
as  a  symptom  of  the  later  stages.  The  vomiting  was  severe  in  one-third 
of  the  cases  in  which  its  presence  was  noted,  and  it  is  described  as  slight 
in  only  five  cases.  The  vomiting  may  be  continuous,  or  occur  at  long- 
intervals,  and  in  some  cases  it  even  ceased  entirely  for  some  time,  return- 
ing later.  The  contents  of  the  stomach  were  first  expelled,  and  then 
bilious  matter.  In  five  cases  blood  was  present  (including  two  cases  of 
dark  brown  vomit),  in  one  in  clots.  The  ruptures  were  situated  in  the 
duodenum,  jejunum,  ileum  (two  cases),  and  "  small  intestine,"  showing 
that  hsematemesis  does  not  indicate  a  rupture  near  the  stomach.  In  two 
of  these  cases  there  was  severe  hemorrhage  into  the  peritoneal  cavity, 
and  in  one  of  them  the  stool  was  also  bloody,  complete  rupture  of  the 
jejunum  having  occurred,  and  the  blood  probably  finding  its  way  into 
the  peritoneal  cavity,  and  into  both  ends  of  the  bowel  from  an  injured 
vessel  on  the  edge  of  the  wound.  When  life  lasts  for  some  time  the 
vomiting  may  become  fecal,  but  the  study  of  this  symptom  must  be 
deferred  for  the  present. 


334 


CURTIS,  RUPTURE    OF   THE  INTESTINE. 


Constipation  will  be  seen  to  be  the  rule,  but  it  must  also  be  considered 
with  the  late  symptoms,  for  the  fact  that  no  stool  was  passed  in  the  first 
six  hours  would  be  of  no  clinical  importance. 

Urinary  symptoms.  These  are  important  in  excluding  injury  of  the 
bladder  and  kidney.  The  character  of  the  urine  is  unchanged  in  uncom- 
plicated rupture  of  the  intestine,  yet  there  are  two  cases  in  which  the 
urine  was  slightly  bloody ;  the  account  of  the  autopsy  not  explaining 
this  symptom,  which  must  have  been  due  to  some  slight  contusion  of  the 
bladder  or  kidney.  But  the  functions  of  the  bladder  are  very  frequently 
disturbed.  Their  condition  is  noted  in  47  of  the  cases.  Ketention  was 
present  in  25  cases  (one  had  stricture).  Urination  was  difficult  in  1 
case,  and  normal  in  17  cases — less  than  50  per  cent.  Tenesmus  was 
present  in  4  cases. 

The  retention  is,  doubtless,  to  be  looked  upon  as  part  of  the  condition 
of  shock,  but  the  tenesmus  is  not  easy  to  explain.  In  one  case  there 
was  severe  hemorrhage  into  the  belly,  and  this  may  have  been  the  cause 
of  the  tenesmus.  Suppression  of  urine  occurred  in  one  case — probably 
due  to  the  severe  shock  present,  from  which  the  patient  never  reacted, 
although  life  lasted  three  or  four  days. 

Pain.  Pain  in  the  abdomen  is  one  of  the  first  and  most  constant 
of  the  symptoms  of  rupture  of  the  intestine,  and  it  is  usually  severe. 
Pain  was  present  in  104  cases — 92  per  cent. ;  and  absent  in  9  cases — 8 
per  cent.  It  was  severe  in  74  cases — 89  per  cent. ;  and  slight  in  9  cases 
— 11  per  cent. 

The  pain  may  be  burning  or  twisting,  continuous  or  lacinating,  but 
usually  resembles  the  pain  of  colic.  It  may  begin  as  a  slight  pain,  and 
grow  worse  gradually  or  suddenly,  or  it  may  continue  slight  throughout. 
In  some  cases  it  ceased  for  a  time,  after  longer  or  shorter  duration.  In 
nearly  all  the  cases  in  which  it  was  delayed,  in  common  with  the  other 
symptoms,  it  appeared  suddenly,  and  as  the  forerunner  of  speedy  and 
fatal  collapse.  It  is  frequently  so  intense  that  morphine  seems  powerless 
to  relieve  it. 

Pain  was  absent  in  the  early  stage  in  9  cases,  but  developed  later 
in  6  of  these.  One  of  the  six  was  a  man  who  was  kicked  by  another 
upon  an  old  hernia,  and  had  no  symptoms  for  six  hours,  and  the  delay 
was  probably  due  to  the  fact  that  the  extra vasated  fecal  matter  did  not 
at  once  reach  the  general  peritoneal  cavity.  There  was  no  pain  through- 
out the  course  of  the  case  in  two  remarkable  instances,  which  follow. 

A  boy,1  six  years  of  age,  was  crashed  between  a  wagon  and  a  fence.  The 
only  symptoms  present  were  weakness,  vomiting,  and  constipation.  Death 
occurred  in  two  and  a  half  days.  Autopsy  showed  a  rapture  extending 
entirely  across  the  ileum,  and  peritonitis. 


1  Bentley  :  Pacific  Medical  and  Surgical  Journal,  1872,  vi.  p.  128. 


CURTIS,   RUPTURE    OF   THE  INTESTINE. 


335 


A  man,1  thirty-six  years  old,  suffering  from  general  paralysis  of  the  insane, 
fell  while  running  away  from  an  attendant,  and  the  latter  fell  upon  him. 
Vomiting  and  hiccough  were  present,  but  he  felt  no  pain  at  any  time,  and 
lived  for  three  days.  Autopsy  showed  a  rupture  of  the  jejunum  the  size  of  a 
quill,  with  peritonitis. 

Early  collapse  will  frequently  cause  the  pain  to  be  apparently  absent 
in  the  first  hours  after  the  injury ;  and  opium  used  in  treatment  may 
conceal  it  at  a  later  period,  therefore  care  is  necessary  to  exclude  these 
sources  of  error. 

Tenderness.  We  have  notes  as  to  the  existence  of  tenderness  in  the 
early  period  in  62  cases.  Tenderness  was  present  in  55  cases — 89  per 
cent. ;  and  absent  in  7  cases — 11  per  cent.  It  is  described  as  great  in  20 
cases,  and  as  slight  in  4  cases.  In  one  of  the  cases  in  which  it  was 
absent  the  statement  is  made  that  the  pain  was  relieved  by  pressure.  Of 
the  seven  cases  in  which  tenderness  was  absent  at  first,  its  later  appear- 
ance is  noted  in  three,  and  one  other,  a  child  of  four  years,  run  over  by 
a  dray,  was  in  collapse  from  the  time  of  the  accident  until  death,  five 
hours  later.  In  the  remaining  cases  no  mention  is  made  of  its  later 
development,  although  life  lasted  one,  two,  and  two  and  a  half  days. 
The  following  case  is  remarkable  for  the  slight  pain  and  tenderness : 

A  man,2  thirty-two  years  old,  fell  twenty  feet,  from  a  tree,  flat  upon  the 
ground,  face  downward,  but  arose  and  walked  two  hundred  yards.  In  one 
hour  there  was  pain  in  the  abdomen,  very  little  shock,  and  retention  of  urine. 
In  three  hours  he  vomited  a  little  blood  in  clots,  and  the  temperature  rose  to 
100.6°  F.,  but  he  remained  cheerful.  In  twenty  hours  he  could  bear  firm 
pressure  on  the  belly,  but  there  was  tenderness  in  the  iliac  region.  In  twenty- 
four  hours  the  belly  was  distended,  he  had  pain  for  one  hour,  but  it  passed  off. 
He  remained  comfortable  and  cheerful,  and  died  quietly  thirty-six  hours  after 
the  accident.  A  rent  in  the  ileum,  which  admitted  three  fingers,  was  dis- 
covered on  autopsy. 

Distention  of  the  abdomen.  This  condition  was  present  early  in  33 
cases,  and  later  in  9 — a  total  of  42.  In  5  cases  the  belly  is  described  as 
tense.  Distention  occurred  at  once  in  2  cases ;  in  1  case  it  occurred 
"  soon ; "  in  another  it  immediately  followed  the  reduction  of  a  hernia 
upon  which  the  blow  had  been  received ;  and  in  1  case  it  took  place 
suddenly  when  the  patient  went  to  the  closet  to  stool,  some  hours  after 
the  accident.  Distention  was  absent  at  first  in  16  cases,  but  it  probably 
occurred  later  in  most  of  those  who  live  long  enough  to  develop  perito- 
nitis. 

Tension  of  the  abdominal  muscles.  In  8  cases  the  abdomen  is  de- 
scribed as  "tense,"  or  "  rigid,"  or  "hard."  In  8  the  abdomen  was 
"  soft,"  or  "  natural,"  and  in  8  others  there  seems  to  have  been  no  con- 
traction of  the  abdominal  muscles.  Therefore,  the  flat  and  tense  belly, 
which  is  looked  upon  by  some  as  symptomatic  of  perforation  of  the  gut, 

1  Yellowlees :  Glasgow  Medical  Journal,  1875,  vii.  p.  415. 

2  Mao  Lean  :  British  Medical  Journal,  1884,  i.  p.  267. 


336 


CUKTIS,   RUPTUEE   OF  THE  INTESTINE. 


is  frequently  absent,  for  we  have  seen  that  the  belly  is  usually  distended 
and  even  when  flat  it  is  more  frequently  soft  than  hard. 

Tympanitic  resonance.  The  percussion  note  was  tympanitic  in  25 
cases  in  the  early  stage,  and  later  in  6  others.  In  4  cases  this  is  the 
only  description  given  of  the  belly,  leaving  us  in  doubt  as  to  whether 
distention  was  present  or  not,  but  in  only  1  case  is  it  expressly  stated 
that  there  was  no  distention.  We  may  fairly  assume  that  the  percussion 
note  was  tympanitic  in  the  cases  in  which  distention  was  present.  This 
would  increase  the  total  to  36  cases. 

Dulness  on  percussion.  In  6  cases  an  area  of  dulness  was  detected  in 
the  early  stage,  and  in  only  2  later. 

Loss  of  liver  dulness.  The  disappearance  of  the  dulness  on  percus- 
sion over  the  site  of  the  liver  has  long  been  considered  a  valuable  sign 
in  perforation  of  the  intestine.  Its  uncertainty  has  also  been  frequently 
alluded  to,  especially  its  uncertainty  as  a  negative  sign.  In  only  4  of 
the  cases  collected  has  this  point  been  noted.  In  3  cases  the  liver  dul- 
ness persisted,  but  in  1  of  these  the  perforation  was  in  the  duodenum 
and  extraperitoneal.  In  1  case1  the  results  of  percussion  were  at  first 
normal,  but  in  twelve  hours  tympanites  developed  and  the  liver  dulness 
disapppeared.  We  have  then  2  cases  in  which  it  persisted  to  1  in  which 
it  was  lost.  The  latter  case,  indeed,  is  conclusive  evidence  that  loss  of 
liver  dulness  is  not  an  immediate  and  necessary  consequence  of  perfora- 
tion of  the  bowel,  else  it  would  have  occurred  in  that  case  at  once,  if 
at  all. 

It  is  evident  that  this  sign  depends  upon  certain  conditions.  There  must 
be  gas  in  the  intestine,  and  it  must  escape  before  adhesions  which  could 
limit  it  have  time  to  form ;  for  although  it  is  possible  for  gas  to  be  gener- 
ated in  the  peritoneal  cavity  this  is  a  rare  occurrence.  The  liver,  too, 
must  be  free  from  adhesions  which  would  retain  it  in  its  position.  Even 
as  a  positive  sign,  loss  of  liver  dulness  caunot  be  relied  upon,  unless  it  is 
certain  that  it  had  been  present  previously.  The  various  conditions 
which  might  mislead  in  this  respect  are  cirrhosis,  backward  dislocation 
of  the  liver,  extreme  tympanites,  or  an  actual  misplacement  of  the  colon 
between  the  liver  and  the  abdominal  wall.  The  first  condition  could 
scarcely  lead  to  error,  for  there  would  be  the  presence  of  other  symp- 
toms of  the  disease,  even  in  the  absence  of  any  history.  Dislocation  of 
the  liver  is  a  very  rare  condition,  and  so  is  the  misplacement  of  the 
colon,  but  if  the  latter  ever  occurs  during  life  it  would  be  likely  to  be 
found  after  such  severe  disturbance  of  the  abdominal  organs  as  must  be 
occasioned  by  the  great  force  which  produces  these  injuries.  Extreme 
tympanites  is  the  condition  which  will  most  frequently  trouble  the  sur- 
geon in  this  respect,  but  if  the  liver  has  been  forced  above  its  normal 

1  Beck  :  Deutsche  Zeitschr.  f.  Chirurgie,  xv.  i.  p.  11. 


CURTIS,   RUPTURE   OF   THE   INTESTINE.  337 

position  that  fact  can  generally  be  determined  by  careful  examination 
of  the  thorax.  We  may,  therefore,  conclude  that  total  absence  of  liver- 
dulness  is  a  tolerably  certain  proof  of  rupture  of  the  intestine  in  these 
cases,  but  that  its  persistence  is  of  no  value  as  a  sign  that  there  is  no 
perforation.1 

Later  Symptoms  and  Course. — The  later  symptoms  are  chiefly 
those  of  peritonitis,  or  septicaemia.  We  must  give  fuller  consideration 
to  the  temperature,  the  constipation,  and  the  fecal  vomiting. 

Temperature.  The  temperature  is  noted  in  38  cases.  In  7  cases  there 
was  no  rise  at  any  time,  and  in  4  of  these  the  temperature  was  sub- 
normal throughout.  The  average  duration  of  life  in  these  8  cases  was 
forty-four  hours — not  much  less  than  what  we  shall  find  to  be  the  average 
duration  in  all  cases — forty-eight  hours.  Of  the  31  cases  with  fever,  the 
rise  began  during  the  first  six  hours  in  7  cases,  during  the  first  twelve 
hours  in  15  cases,  and  in  all  but  5  cases  during  the  first  twenty -four 
hours.  One  exceptional  case  had  no  fever  until  the  fourth  day.  The 
highest  temperature  of  the  first1  six  hours  was  39°  C.  The  average 
duration  of  life  in  the  30  cases  with  fever  (one  case  being  omitted,  because 
laparotomy  was  performed)  was  sixty  hours. 

Constipation.  In  22  cases  there  was  no  stool  until  death — an  average 
of  three  and  one-half  days,  and  in  3  others  the  bowels  were  moved  by 
purgatives.  In  5  cases  the  bowels  Avere  moved,  and  in  1  of  these  there 
was  diarrhoea,  but  the  latter  may  have  been  accidental,  and  not  caused 
by  the  injury.  Blood  was  present  in  the  stools  in  only  1  case,  and  in 
another  the  stools  were  black.  This  fact  and  the  prevailing  constipation 
show  how  valueless  the  well-known  symptom  of  "bloody  stools"  will 
prove  in  diagnosis. 

Fecal  vomiting.  Fecal  vomiting  occurred  in  12  of  the  cases  collected, 
being  nearly  10  per  cent,  of  the  whole,  and  17  per  cent,  of  all  the  cases 
in  which  vomiting  took  place.  It  is,  therefore,  rather  a  common  symp- 
tom. Fecal  vomiting  began  as  early  as  twelve  hours  after  the  acci- 
dent in  1  case,  and  in  7  cases  within  the  first  thirty-six  hours ;  in  the 
other  5  cases  it  began  on  the  third  to  the  fifth  day.  In  2  cases  there 
had  been  no  previous  vomiting,  and  in  these  the  fecal  vomiting  began 
late.  In  5  of  the  cases  there  was  no  stool,  and  in  the  rest  the  state  of 
the  bowels  is  not  described,  but  as  all  but  1  of  these  died  within  thirty 
hours  of  the  accident  their  testimony  is  not  important.  When  the  case 
is  obscure,  and  fecal  vomiting  and  constipation  are  both  present,  the 
likeness  to  intestinal  obstruction  may  be  very  close — as  it  is  in  those 
cases  of  non-traumatic  perforation-peritonitis  in  which  laparotomy  has 
been  performed  under  a  mistaken  diagnosis.  In  one  of  the  cases  which 
began  late,  autopsy  showed  a  complete  obstruction  of  the  gut  at  the  point 

1  For  a  full  discussion  of  this  question  see  Ebstein's  paper  on  perforation-peritonitis,  Zeitschr.  f. 
klin.  Med.,  1885,  ix.  p  209. 

NO.  CLXXXVIII. — OCTOBER,  1887.  22 


338 


CUKTIS,  RUPTURE   OF   THE   INTESTINE . 


of  rupture.  In  the  other  late  cases  it  may  have  been  caused  by  the 
mechanical  obstruction  caused  by  the  forming  adhesions.  But  in  the 
early  cases  it  is  not  so  easy  to  explain,  although  a  similar  symptom  is 
found  in  peritonitis  due  to  perforating  ulcer  of  the  intestine.  We  might 
suppose  a  spasmodic  or  paralytic  obstruction  caused  by  the  shock  due 
to  the  injury,  to  the  beginning  peritonitis,  or  to  the  mere  presence  of 
fecal  matter  in  the  peritoneal  cavity— but  the  whole  matter  is  as  yet 
too  obscure  to  warrant  even  a  supposition. 

The  peritonitis  which  the  fecal  vomiting  accompanied  was  evidently 
septic  or  purulent,  except  in  two  cases  which  are  described  as  "  fibrin- 
ous," and,  perhaps,  here  also,  for  it  is  not  easy  to  exclude  the  septic 
element  in  such  cases,  yet  in  one  of  these  there  was  no  fecal  extravasa- 
tion to  be  detected. 

The  situation  of  the  rupture  in  the  bowel  seems  to  exercise  no  influ- 
ence upon  the  occurrence,  or  the  time  of  appearance  of  this  symptom, 
for  it  accompanies  ruptures  in  all  parts  of  the  intestinal  canal. 

Fecal  vomiting  was  usually  a  sign  of  impending  dissolution,  appear- 
ing within  twelve  hours  of  death  in  5  cases,  although  2  cases  lived  three 
days  after  it  began.  The  prognosis  is  worst  when  it  begins  in  the  first 
twenty-four  hours,  for  of  6  such  cases  5  died  within  thirty  hours  after 
the  accident.  All  the  cases  in  which  fecal  vomiting  occurred  are 
divisible  into  two  classes :  5  cases  which  died  within  thirty  hours  of  the 
accident,  and  7  cases  which  lived  from  three  to  eight  days,  and  there  is 
a  remarkable  absence  of  cases  living  what  Ave  shall  find  to  be  the  most 
common  length  of  life  after  the  accident — forty-eight  hours. 

Course. — In  studying  the  course  of  rupture  in  the  intestine  we  must 
distinguish  three  sets  of  cases  : 

In  the  first  set  the  shock  caused  by  the  accident  never  leaves 
the  patient,  may  never  diminish,  but  passes  rapidly  or  slowly  into  a 
collapse  which  lasts  until  death.  While  this  is  a  characteristic  of  the 
cases  in  which  hemorrhage  accompanies  the  injury,  it  is  not  confined  to 
them,  for  we  have  seen  that  the  accident  itself,  or  fecal  extravasation 
(occurring  at  the  time,  or  subsequently)  may  produce  a  collapse  which 
will  prove  fatal  in  a  few  hours.  In  this  set  of  cases  the  duration' of  life 
is  short,  and  may  be  even  less  than  an  hour,  but  occasionally  it  may  be 
prolonged  for  days.  When  death  is  delayed,  it  is  impossible  to  distin- 
guish the  boundary  line  dividing  shock  from  septic  poisoning,  but  the 
latter  is  the  true  cause  of  death  if  death  does  not  occur  soon  after  the 
accident,  unless  fecal  extravasation  has  also  been  delayed.  In  the  rare 
cases  in  which  symptoms  do  not  develop  immediately,  the  clinical  history 
begins  with  the  first  appearance  of  the  symptoms,  rather  than  with  the 
accident.  The  still  rarer  cases  in  which  there  is  no  shock  at  any  time 
must  be  classified  with  the  following — omitting  the  first  stage  of  shock 
and  reaction. 


CURTIS,  RUPTURE    OF   THE  INTESTINE. 


339 


The  second  set  of  cases  includes  those  in  which  a  frank  peritonitis 
develops,  with  abdominal  pain  and  tenderness,  tympanites,  and  fever 
after  the  shock  has  passed  off.  These  are  the  cases  in  which  the  diag- 
nosis is  easiest,  but,  unfortunately,  they  are  not  the  most  common. 

The  third  set  of  cases  is  the  most  numerous.  It  comprises  those 
in  which,  instead  of  an  evident  peritonitis  after  reaction  from  the  shock 
has  taken  place,  there  are  vague  symptoms  which  keep  the  surgeon  in 
expectation  that  peritonitis  is  about  to  develop,  but  nothing  upon  which 
he  can  found  a  positive  diagnosis,  for  such  light  indications  are  common 
enough  in  the  cases  in  which  ultimate  recovery  has  taken  place.  The 
patient  lies  in  a  state  of  apathy,  seemingly  satisfied  with  his  condition, 
and  thus  misleads  those  about  him ;  or  he  becomes  gradually  weaker, 
and  because  less  able  to  complain,  appears  to  be  improving ;  or  the 
symptoms  of  peritonitis  develop  by  degrees,  and  so  slowly  that  no  one 
can  say  of  any  moment  that  it  marked  the  beginning. 

Prognosis. — The  prognosis  in  rupture  of  the  intestine  may  be  said  to 
be  absolutely  bad,  for  even  a  suppositious  case  of  recovery  after  this  ac- 
cident is  so  rare  as  to  be  a  surgical  curiosity.  The  following  case1  pos- 
sesses great  interest  in  this  connection : 

A  blacksmith,  forty-seven  years  of  age,  was  struck  in  the  right  iliac  region 
by  the  butt  of  a  shotgun,  which  discharged  unexpectedly  while  he  was-  hold- 
ing it.  He  immediately  felt  chilly  and  weak,  and  agonizing  pain  and  vomit- 
ing soon  set  in.  In  forty  eight  hours  he  was  suffering  from  an  acute  attack 
of  peritonitis,  the  belly  somewhat  swollen  and  hard.  At  the  site  of  the 
injury  there  were  tenderness  and  dulness  on  percussion  ;  elsewhere  tympanitic 
resonance.  There  was  no  external  mark  of  injury.  The  stomach  rejected 
everything ;  there  had  been  no  stool.  He  was  very  sick  for  five  days,  then 
improved.  Ten  days  after  the  injury,  getting  out  of  bed,  he  became  entangled 
in  the  blanket  and  fell  upon  the  floor,  face  downward.  Immediately  he  had 
frightful  pain  in  the  belly,  vomiting  began,  collapse  set  in,  and  he  died  in 
fourteen  hours.  The  autopsy  showed  the  omentum  adherent  to  the  wall  of 
the  abdomen  at  the  site  of  the  blow,  the  intestines  adherent  and  injected. 
Between  the  parietal  peritoneum  and  the  muscles  was  an  extravasation  of 
blood,  the  size  of  the  palm  of  the  hand.  In  a  loop  of  intestine,  lying  half 
way  between  the  umbilicus  and  the  pubes,  was  a  rent  admitting  four  finger- 
tips.   Fecal  extravasation. 

It  is  probable  that  in  this  case  a  small  rupture  took  place  at  the  time 
of  the  blow,  with  an  extensive  contusion  of  the  gut.  Adhesions  closed 
in  both,  and  the  fall  separated  these  and  also  tore  open  the  weakened 
contused  part. 

Duration  of  life.  An  average  computed  on  112  cases  gives  the  dura- 
tion of  life  after  the  accident  as  forty-eight  hours.  That  this  average 
is  not  obtained  by  the  union  of  extremes,  but  is  a  natural  one,  is  shown 
by  the  fact  that  8  cases  died  in  the  first  twelve  hours,  52  cases  (46  per 
cent.)  in  the  first  twenty -four  hours,  and  82  cases  (73  per  cent.)  in  the 
first  forty-eight  hours.    4  cases  lived  eight  days. 


J  Atlee  :  Med.  and  Surg.  Reporter,  Hi.  p.  6,  1885. 


340 


CURTIS,  RUPTURE   OF   THE  INTESTINE. 


Evidently  nothing  is  to  be  hoped  from  nature,  and  whatever  improve- 
ment is  to  be  made  in  the  prognosis  must  be  obtained  by  operative  treat- 
ment. The  history  of  what  the  latter  has  done  up  to  the  present  time 
can  be  told  in  a  few  words.  Omitting  the  cases  of  rupture  of  the  intes- 
tine in  a  hernial  sac,  treated  only  by  the  ordinary  operation  for  hernia, 
there  have  been  recorded  eight  cases1  of  laparotomy  with  treatment  of 
the  ruptured  intestine — six  times  by  suture,  twice  by  the  clamp.  Of 
these  cases,  six  died  soon  after  the  operation;  Bouilly's  case  lived  ten 
days ;  Croft's  four  weeks. 

In  addition  to  these  cases,  laparotomy  has  been  performed  four  times 
after  contusion  of  the  abdomen,2  the  lesions  present  being  contusion  of 
the  colon  and  pancreas,  rupture  of  the  spleen  (two  cases),  and  rupture 
of  the  liver.  These  five  cases  terminated  fatally,  but  the  operation 
did  no  injury,  and  in  some  instances  brought  about  a  temporary  im- 
provement. 

Two  of  the  cases  of  laparotomy  for  rupture  of  the  intestine  can  be 
claimed  as  recoveries,  for  Bouilly's  case  died  of  a  fresh  peritonitis  set 
up  by  a  rough  examination  of  the  artificial  anus,  when  the  original 
inflammation  had  entirely  subsided ;  and  Croft's  case  apparently  died 
of  inanition  due  to  the  artificial  anus.  In  all  the  other  cases  the  opera- 
tion was  undertaken  so  long  after  the  injury  that  there  was  no  hope  for 
success.  These  two  cases,  however,  with  the  case  reported  by  Mikulicz,3 
prove  that  a  peritonitis  with  fecal  extravasation  is  amenable  to  surgical 
treatment.  We  may,  then,  confidently  expect  better  things  in  the 
future,  although  the  cases  with  very  obscure  symptoms,  and  those  in 
which  collapse  sets  in  very  early,  must  always  remain  beyond  the  reach 
of  treatment. 

Diagnosis. — In  attempting  to  make  a  diagnosis  of  the  precise  injury 
produced  by  a  contusion  of  the  abdomen,  the  cause  of  the  injury  and 
the  exact  situation  of  the  blow  should  first  be  ascertained  as  accurately 
as  possible.  Certain  causes,  especially  the  kick  of  a  horse  or  man,  have 
been  shown  to  be  particularly  liable  to  produce  rupture  of  the  intestine. 
The  site  of  the  blow,  too,  will  often  give  a  clew  to  the  organ  which  has 
been  injured — the  liver,  spleen,  or  bladder.  In  order  to  cause  a  rupture 
of  the  intestine,  the  blow  must  be  so  directed  as  to  crush  the  gut  be- 
tween the  contusing  body  and  the  spine  or  pelvis.  The  existence  of 
hernia,  the  presence  of  bowel  in  the  hernial  sac,  and  the  wearing  of  a 
truss  at  the  time  of  the  accident,  all  increase  the  liability  to  rupture  of 

1  Dr.  Gregory  (operated  1876,  St.  Louis)  :  Brit.  Med.  Journ.,  1887,  i.  p.  1037.  Demons  :  Kev.  de 
Chir.,  May,  1885,  p.  421.  Girdlestone  :  Austral.  Med.  Journ.,  1883,  v.  p.  100.  Fitzgerald  ;  Ibid.,  p.  264. 
Bouilly :  Bull.  Soc.  de  Chir.,  Paris,  1883,  ix.  p.  698.  E.  Owen  :  Lancet,  1885,  ii.  p.  663.  Waggener  : 
St.  Louis  Cour.  of  Med.,  188C,  xvi.  p.  204.    Croft :  Brit.  Med.  Journ.,  1887,  i.  p.  975. 

2  Chavasse :  Bull.  Soc.  de  Chir.,  Paris,  1885,  xi.  p.  123.  -  Willett :  St.  Barth.  Hosp.  Eep.,  xix.  p.  203. 
Mackellar:  Brit.  Med.  Journ.,  1887,  i.  p.  1037.    Croft:  Ibid.,  p.  976. 

3  Volkmaun's  Saniml.  klin.  Vortrage,  No.  262,  p.  2315. 


CURTIS,  RUPTURE   OF  THE  INTESTINE. 


341 


the  intestine.  A  former  attack  of  peritonitis,  or  the  presence  of  hardened 
feces  in  the  intestine  would  also  naturally  increase  the  danger. 

Contusion  of  the  abdomen,  with  recovery.  About  four-fifths  of  all 
cases  of  contusion  of  the  abdomen  end  in  recovery.  Thus  Bryant  (Sur- 
gery, fourth  edition,  p.  485)  states  that  in  seventy-one  consecutive  cases 
of  contusion  of  the  abdomen  treated  in  Guy's  Hospital,  there  was  injury 
to  some  of  the  viscera  in  seventeen,  there  was  peritonitis  ending  in  re- 
covery in  ten,  and  in  the  remainder  the  symptoms  were  of  short  dura- 
tion, and  there  was  evidently  no  visceral  injury.  A  number  of  cases  of 
contusion  of  the  abdomen  ending  in  recovery  have  been  collected  and 
studied,  with  especial  reference  to  the  symptoms  of  the  first  six  hours 
after  the  accident,  in  the  same  manner  as  the  cases  of  rupture  of  the 
intestine.  Almost  all  of  these  cases  have  been  collected  from  literature, 
and  therefore  represent  the  severest  forms  of  this  injury. 

Let  us  consider  the  symptoms  of  these  thirty-three  cases  in  the  same 
order  as  has  been  followed  for  those  of  rupture  of  the  intestine.  In 
simple  contusion  of  the  abdomen  the  symptoms  are  at  their  worst  at  first, 
and  in  nearly  all  the  cases  a  progressive  improvement  was  observed 
when  the  change  had  once  begun.  But  some  of  them  developed  perito- 
nitis— fever,  abdominal  pain,  and  tenderness,  tympanites,  and  vomit- 
ing being  present  as  its  symptoms.  In  a  solitary  case1  the  patient 
rallied  from  the  shock  which  was  present  at  first,  and  relapsed  later. 
But  this  is  so  rare  an  occurrence  that  such  a  relapse  is  an  almost  certain 
sign  of  internal  hemorrhage  or  injury  to  some  of  the  viscera. 

Shock  was  present  in  28  cases,  absent  in  only  1 — a  far  larger  per- 
centage than  in  rupture  of  the  intestine.  The  shock  was  severe  in  a 
remarkably  large  number — 18  cases  (66  per  cent.);  while  it  is  noted  as 
slight  in  only  4  cases.  The  shock  was  also  very  frequently  of  long 
duration — in  60  per  cent,  of  the  cases.  In  only  6  cases  was  it  noted  as 
short.  In  6  cases  it  lasted  several  hours,  and  in  3  cases  twelve,  twenty- 
four,  and  sixty  hours  respectively. 

Restlessness  was  present  in  only  3  cases,  in  2  of  which  it  was  great, 
evidently  due  to  internal  hemorrhage. 

Vomiting  was  present  in  14  cases,  4  of  which  are  said  to  have  been 
severe,  and  2  slight.  It  is  noted  as  absent  in  10  cases,  but  in  4  of  these 
there  was  nausea.  Vomiting  appeared  later  in  5  cases  in  which  it  had 
not  been  present  at  first,  usually  as  a  symptom  of  peritonitis.  Fecal 
vomiting  was  never  noted,  but  in  2  cases  the  vomited  matter  is  de- 
scribed as  "altered  blood"  and  "dark  like  feces."  Vomitiug,  then,  is 
less  severe  than  in  rupture  of  the  intestine. 

The  stools  contained  blood  only  once.  Constipation  was  the  rule,  but 
was  probably  due  to  opium  in  most  cases.   7  cases  had  no  stool  for  from 

1  Le  Gros  Clark  :  Diagnosis  of  Visceral  Lesions.  Loudon,  1870,  p.  266.  (Supposed  rupture  of  the 
liver.) 


342 


CURTIS,  RUPTURE   OF   THE  INTESTINE. 


two  to  four  days;  in  1  the  bowels  were  regular;  2  had  passages  very- 
soon  after  the  accident,  followed  by  constipation;  and  1  had  a  free 
diarrhoea  on  the  fifth  day. 

The  urine  was  bloody  in  3  cases ;  in  1  from  contusion  of  the  kidney, 
and  in  1  perhaps  from  contusion  of  the  bladder.  Retention  of  urine 
was  present  in  one-third  of  the  cases  in  which  the  function  of  the  bladder 
is  noticed. 

Pain  was  present  in  the  abdomen  in  29  cases,  in  14  of  which  it  was 
severe,  and  the  pain  may  be  as  great  as  in  any  case  of  rupture  of  the 
intestine.  Tenderness  was  present  in  20  cases,  in  8  of  which  it  was 
described  as  great,  and  in  2  slight.  There  was  no  tenderness  in  1  case, 
but  it  developed  later  also  in  this. 

Physical  signs.  In  4  cases  the  abdominal  muscles  were  tense.  The 
abdomen  was  distended  in  12  cases  in  the  early  stage,  and  in  2  others 
later,  and  distention  is  noted  as  absent  in  1  case.  This  distention  may 
occur  immediately  after  the  injury,  proving  that  it  must  be  a  result  of 
shock  to  the  nervous  centres,  and  very  closely  simulating  rupture  of  the 
intestine,  with  escape  of  gas  into  the  peritoneal  cavity. 

Tympanitic  resonance  was  present  early  in  7  cases,  and  in  1  later. 
Dulness  on  percussion  was  present  in  4  cases — in  1  at  the  site  of  the 
blow,  and  in  1  a  movable  dulness  indicating  fluid  (blood)  in  the  belly. 
The  condition  of  the  area  of  liver  dulness  is  not  given  in  a  single  case. 

In  fact,  the  symptoms  are  almost  identical  with  those  of  rupture  of 
the  intestine,  except  in  intensity  and  duration. 

In  a  few  cases  of  contusion  of  the  abdomen  it  will  be  possible  to  decide 
what  organs  have  been  injured,  but  in  by  far  the  greater  number  of 
cases  a  diagnosis  cannot  be  made.  Thus  local  pain  and  tenderness  would 
indicate  rupture  of  the  liver,  spleen,  or  bladder;  bloody  urine,  reten- 
tion, tenesmus,  and  the  facts  learned  by  catheterization  would  allow  of 
a  diagnosis  of  rupture  of  the  bladder ;  free  blood  or  urine  might  give 
an  area  of  dulness  on  percussion  changing  with  position ;  signs  of  in- 
ternal hemorrhage  would  make  rupture  of  the  liver  or  spleen  probable, 
and  next  to  these  laceration  of  the  mesentery ;  absence  of  these  symp- 
toms, and  the  presence  of  severe  shock,  great  abdominal  pain  and  ten- 
derness, severe  vomiting,  and  early  development  of  peritonitis  would 
favor  rupture  of  the  intestine.  It  will  seldom  be  possible  to  decide, 
during  the  first  six  hours  or  more  after  the  accident,  whether  the  intes- 
tine has  been  ruptured  or  not.  However  slight  the  symptoms  may  be, 
it  cannot  be  justifiable  to  declare  that  no  visceral  injury  has  resulted 
until  several  days,  free  from  symptoms,  have  elapsed,  for  the  symptoms 
may  remain  latent  after  injury  to  almost  any  of  the  abdominal  organs, 
and  such  a  course  is  not  infrequent  with  rupture  of  the  intestine  and 
bladder.  Even  when  the  contusing  force  -  has  been  apparently  trifling 
the  greatest  care  should  be  exercised  in  giving  a  prognosis.    If  the 


CURTIS,   RUPTURE    OF   THE  INTESTINE. 


343 


visceral  injury  is  merely  a  contusion  of  the  intestine,  the  appearance  of 
serious  consequences  may  be  delayed  as  much  as  a  fortnight.1 

Treatment. — Since  the  establishment  of  the  rule  that  in  penetrating 
gunshot  wounds  of  the  abdomen,  immediate  laparotomy  is  necessary, 
without  waiting  for  symptoms  of  injury  to  the  intestine,  some  have  sought 
to  extend  the  application  of  this  principle  to  penetrating  stab-wounds, 
and  to  all  severe  contusions  of  the  belly.  It  is  true  that  if  rupture  or 
severe  contusion  of  the  intestine  has  taken  place,  death  is  inevitable, 
unless  laparotomy  is  performed  at  a  very  early  period,  just  as  this  is 
true  of  gunshot  wound  of  the  bowel.  But  the  intestine  will  almost 
certainly  be  wounded  with  penetrating  gunshot  wound  of  the  belly, 
while  in  the  severest  forms  of  contusion,  let  the  force  be  the  most  violent 
and  the  symptoms  the  most  acute,  there  are,  as  we  have  already  shown, 
many  chances  that  the  gut  shall  escape  unhurt.  Accordingly,  the  treat- 
ment of  contusions  of  the  abdomen  must  be  wholly  symptomatic — the 
surgeon  having  no  right  to  assume  that  rupture  of  the  intestine  has 
taken  place  until  symptoms  appear  which  indicate  its  occurrence. 

If  it  is  apparent  that  hemorrhage  is  present,  we  should  try  to  control 
it  by  pressure  upon  the  abdomen,  a  firm  pillow  being  bound  upon  it  as 
tightly  as  can  be  endured,  although  one  of  the  experiments  on  dogs 
showed  that  but  little  advantage  is  to  be  gained  from  any  pressure  which 
can  be  borne  without  anaesthesia.  Morphine  should  also  be  given  with 
care  to  quiet  the  circulation,  and  to  relieve  the  intense  pains  in  the 
belly  and  limbs,  sometimes  so  excruciating  that  no  amount  of  the  drug 
consistent  with  safety  can  entirely  prevent  them,  and  stimulants  must  be 
withheld  as  far  as  possible.  If  the  patient  continue  to  sink,  the  surgeon 
should  proceed  at  once  to  laparotomy,  for  many  of  these  cases  bleed  to 
death  from  vessels  which  could  be  easily  reached  and  ligated.  To  inject 
blood  or  salt  solution  into  the  veins  of  a  patient  while  the  blood  is 
escaping  elsewhere,  is  like  pouring  water  into  a  vessel  with  a  hole  in  the 
bottom,  or  as  if  one  should  treat  a  woman,  dying  of  hemorrhage  from 
placenta  prsevia,  by  transfusion  without  putting  a  tampon  in  the  vagina. 

After  the  vessels  have  been  secured,  stimulants  and  transfusion  come 
into  their  proper  place,  and  must  be  called  upon  at  once  to  make  up  the 
loss  of  blood.  Great  collapse  Avould  con  train  dicate  any  operative  inter- 
ference, for  laparotomy  demands  a  certain  amount  of  strength  in  the 
patient,  and  when  the  latter  is  very  weak,  it  is  already  too  late  to  save 
his  life  by  operation. 

If  the  case  present  no  sign  of  hemorrhage,  or  if  the  hemorrhage  soon 
cease,  and  there  are  no  evident  symptoms  of  rupture  of  the  intestine, 
expectant  treatment  must  be  adopted  ;  absolute  rest  in  bed,  very  limited 
fluid  diet,  administered  in  small  quantities,  as  little  morphine  as  possible, 


1  L.  Muguier :  These  de  Paris,  1883,  reviewed  in  Centralbl.  f.  Chir.,  1884,  p.  181. 


344 


CURTIS,  RUPTURE    OF   THE  INTESTINE. 


in  order  not  to  obscure  any  symptoms  about  to  develop,  and  continuous 
watching  of  the  patient  to  detect  the  slightest  change,  for  the  only 
chance  of  success  in  these  operations  depends  upon  their  performance  at 
the  earliest  possible  period,  before  septic  poisoning  and  peritonitis  can 
fully  develop,  and  before  the  strength  of  the  patient  has  been  exhausted 
by  pain  and  vomiting.  Every  rude  method  of  examination,  such  as 
rough  pressure  on  the  abdomen  to  detect  points  of  tenderness,  or  attempts 
to  elicit  "  succussion  sounds,"  are  to  be  carefully  avoided.  Ordinary 
diet,  large  quantities  of  water,  emetics,  purgatives,  and  even  enemata 
are  to  be  absolutely  prohibited.  It  is  important  to  give  no  more 
morphine  than  is  necessary  to  make  the  patient's  sufferings  endurable, 
seeking  rather  to  relieve  pain  by  hot  applications  to  the  abdomen,  if  no 
hemorrhage  is  present.  Morphine  probably  acts  in  peritonitis  only  by 
relieving  pain,  and  diminishing  peristalsis.  If  we  had  the  power  of 
instantaneously  and  completely  paralyzing  the  peristaltic  movements  of 
the  gut  immediately  after  rupture  of  the  intestine  had  taken  place, 
doubtless  the  best  treatment  would  be  to  stop  them  at  once  and  not 
allow  them  to  recommence  until  time  had  been  given  for  the  formation 
of  permanent  adhesions.  But  we  have  no  such  power,  for  it  is  improbable 
that  morphine  can  produce  its  effect  upon  peristalsis  in  time  to  prevent 
fecal  extravasation,  as  the  escape  of  feces  probably  occurs  in  most  cases 
within  a  few  minutes  of  the  accident.  The  benefits  to  be  gained  by 
immediate  and  energetic  use  of  opium  in  these  cases  do  not  counter- 
balance the  greatly  increased  risk  for  the  patient  caused  by  the  conceal- 
ment of  symptoms  upon  the  early  recognition  of  which  his  safety  depends, 
if  rupture  of  the  intestine  has  taken  place. 

A  typical  case  of  rupture  of  the  intestine  would  present  shock,  great 
abdominal  pain  and  tenderness,  severe  vomiting,  and  perhaps  a  rise  of 
temperature  in  the  first  few  hours — the  symptoms  not  improving  with 
time.  The  physical  signs,  abdominal  distention  or  retraction,  loss  of 
liver  dulness,  etc.,  might  or  might  not  be  present.  But  the  chief  dif- 
ference between  these  cases  and  those  in  which  the  intestine  has  escaped 
injury  is  the  persistence  of  the  symptoms,  or  their  continued  aggrava- 
tion, and  sufficient  time  must  be  allowed  to  elapse  to  determine  this 
point — at  least  six  hours.  In  a  well-marked  case  with  these  symptoms, 
laparotomy  is  justifiable.  If  shock,  pain,  or  tenderness  be  absent,  the 
case  is  doubtful,  and  operation  must  be  delayed  until  it  becomes  clearer. 
By  far  the  largest  number  of  cases  will  fall  into  this  latter  category. 
If  there  is  a  strong  probability  of  rupture,  an  explorative  operation  is 
advisable ;  but  the  decision  when  operation  is  indicated,  and  how  far  it 
should  be  carried,  must  be  left  in  each  case  to  the  judgment  of  the  sur- 
geon, as  it  is  impossible  to  formulate  rules  for  distinguishing  cases  which 
shade  off  into  one  another  by  such  insensible  gradations. 


CURTIS,   RUPTURE   OF   THE  INTESTINE. 


345 


A  few  words  are  necessary  in  regard  to  the  technique  of  these  opera- 
tions. 

The  incision  must  be  a  long  one,  for  we  have  to  deal  with  the  normal 
abdomen ;  not  distended,  and  with  atrophied  tissues,  as  in  cases  of 
abdominal  tumor.  The  length  of  the  incision  for  the  exploration  should 
be  at  least  four  inches.  The  length  for  the  complete  operation,  when 
all  the  intestine  is  to  be  drawn  out  for  examination,  and  the  examination 
cannot  be  complete  without  this,  should  be  at  least  eight  inches,  unless 
the  abdominal  walls  are  unusually  relaxed.  The  centre  of  the  incision 
should,  as  a  rule,  be  at  the  umbilicus ;  but  if  it  is  evident  that  the  injury 
was  inflicted  very  high  up,  it  may  be  advisable  to  have  it  an  inch  or  so 
higher,  to  facilitate  examination  of  the  stomach.  The  incision  should 
not  be  made  lower,  for  the  attachment  of  the  mesentery  may  interfere 
with  turning  out  the  intestine,  especially  if  the  mesentery  is  short,  or 
thickened  with  fat. 

The  peritoneum  should  be  inspected  before  it  is  incised.  If  there  be 
blood  in  the  cavity  it  will  probably  make  its  presence  known  through 
the  transparent  membrane,  but  care  must  be  taken  not  to  confound  an 
ecchymosis  of  the  omentum  lying  under  the  incision  with  free  blood,  and 
the  distinction  will  not  always  be  easy.  It  will  be  possible,  also,  to 
ascertain  the  presence  of  gas,  pus,  or  even  congestion  of  the  peritoneum, 
in  some  cases.  The  peritoneum  having  been  inspected  and  incised,  a 
sponge  on  a  long  forceps  is  to  be  passed  into  the  pelvis,  and  examined 
on  withdrawal  for  blood,  pus,  or  feces.  The  same  should  be  done  for 
each  lumbar  region.  It  must  be  remembered  that  fecal  odor  is  not  an 
absolute  proof  of  the  presence  of  feces,  for  a  fluid  in  the  belly  may  con- 
tract this  odor  through  mere  contact  with  the  intestine. 

Parkes  has  already  pointed  out1  that  simply  opening  the  abdomen 
will  often  cause  the  hemorrhage  within  it  to  cease,  the  contact  of  the 
air  making  the  vessels  contract,  and  the  blood  coagulate  more  firmly 
and  rapidly.  While  this  is  true,  especially  when  the  bleeding  proceeds 
from  small  vessels,  the  opening  of  the  belly  removes  from  its  contents 
the  pressure  of  the  abdominal  walls,  and  in  some  cases  the  hemorrhage 
will  increase,  instead  of  diminishing.  Thus,  in  some  of  the  experiments 
upon  dogs,  it  was  observed  that  the  first  serious  symptoms  of  loss  of 
blood  appeared  at  the  moment  when  the  peritoneal  cavity  was  opened, 
and  the  blood  gushed  from  its  interior.  Dennis2  suggests  that  a  tourni- 
quet without  the  pad,  or  an  Esmarch  elastic  tube  be  placed  around  each 
thigh  before  the  cavity  is  opened,  and  kept  in  place  until  the  bleeding 
vessels  have  been  secured,  in  order  to  save  at  least  the  blood  contained 
in  the  lower  extremities. 

1  The  Medical  News,  May  17,  1884,  p.  564. 

2  The  Medical  News,  March  6,  188G,  p.  264. 


346 


CUKTIS,   RUPTURE   OF   THE  INTESTINE. 


In  performing  laparotomy  for  internal  hemorrhage,  every  step  of  the 
operation  should  be  executed  with  the  greatest  rapidity.  As  soon  as 
the  belly  has  been  opened,  and  a  large  amount  of  blood  is  seen  welling 
up  from  the  bottom,  the  operator  should  lift  up  the  omentum,  quickly 
pass  his  left  hand  underneath  it,  upward  and  backward,  and  make 
pressure  upon  the  abdominal  aorta  and  the  root  of  the  mesentery,  at  the 
highest  point  which  can  be  reached.  The  hemorrhage  will  thus  be 
temporarily  controlled.  With  his  other  hand,  and  the  aid  of  his  chief 
assistant,  the  entire  small  intestine  is  to  be  quickly  turned  out,  the 
mesentery  being  inspected  as  this  is  done,  and  any  bleeding  points  seen 
secured  at  once  with  clamps ;  another  assistant  wrapping  the  intestines, 
as  soon  as  brought  out,  in  towels  which  have  been  soaking  in  a  hot  1  to 
4000  bichloride  solution.  The  abdominal  cavity  is  to  be  rapidly  emptied 
of  blood  and  clots,  and  all  bleeding  points  seized.  The  pressure  upon 
the  aorta  may  then  be  gradually  relaxed,  the  operator  watching  to  see 
if  all  the  injured  vessels  have  been  properly  secured. 

Up  to  this  time  stimulants  should  have  been  given  with  caution,  so 
as  not  to  interfere  with  nature's  efforts  to  stop  the  hemorrhage,  but  now 
they  must  be  pushed  with  energy,  and  if  the  patient  is  very  weak,  the 
salt  solution  must  be  prepared  for  transfusion.  All  the  vessels  having 
been  tied  with  catgut,  a  more  careful  examination  of  the  intestine  is  to 
be  made,  to  discover  any  injuries  to  the  gut,  or  any  loops  which  have 
been  deprived  of  their  blood  supply  by  injuries  of  the  mesentery.  Even 
in  the  first  hurried  examination  it  should  be  kept  in  mind  that  rupture 
of  the  gut  may  be  present,  and  if  any  are  found,  the  injured  loops  are 
to  be  wrapped  in  separate  cloths,  to  avoid  the  danger  of  spreading  the 
feces  over  the  mass  of  intestines.  In  these  cases  it  is  probable  that  the 
patient  will  be  too  low  to  admit  of  so  prolonged  an  operation  as  resection 
with  suture,  and  it  will  be  necessary  to  make  an  artificial  anus. 

If  there  were  no  injury  of  the  gut,  the  cleansing  of  the  peritoneal 
cavity,  and  the  inspection  and  return  of  the  intestine  would  require  but 
a  few  minutes,  and  the  abdominal  wound  having  been  partly  closed  by 
the  introduction  of  a  few  deep  sutures,  a  flat  sponge  being  left  inside  as 
a  further  precaution,  the  operator  would  be  at  liberty  to  attend  to  the 
transfusion,  completing  the  closure  of  the  wound  afterward.  Even  if 
the  intestine  were  injured,  all,  except  the  injured  part,  could  be  returned 
after  inspection  and  cleansing,  the  wound  temporarily  closed  as  just  sug- 
gested, and  the  injured  loops  kept  wrapped  up  in  a  warm  cloth  until  the 
operator  had  made  the  transfusion.  This  early  return  of  the  uninjured 
parts  was  repeatedly  found  to  have  a  remarkable  effect  in  improving 
the  pulse  in  the  experiments  on  dogs,  and  will  prove  a  very  useful 
expedient  when  the  shock  is  great ;  in  fact,  the  intestines  should  always 
be  returned  as  soon  as  the  peritoneum  has  been  cleansed. 

But  if  the  hemorrhage  is  not  great,  the  operator  should  lift  up  the 


i   CURTIS,  RUPTURE   OF   THE   INTESTINE.  347 

omentum,  and  carefully  draw  out  the  intestine,  one  loop  at  a  time,  wrap- 
ping the  gut  in  towels  as  he  lays  it  to  one  side,  until  the  whole  has  been 
examined.  It  is  impossible  to  make  a  thorough  examination  without  re- 
moving the  entire  small  intestine  from  the  abdomen.  Attention  should 
first  be  given  to  those  parts  lying  directly  under  the  blow,  for  this  is  most 
frequently  the  situation  of  the  injured  loop.  If  any  injuries  are  found, 
if  they  are  extensive,  and  there  is  much  fecal  extravasation  from  the 
wound,  the  injured  loops  should  be  wrapped  by  themselves  in  a  cloth, 
and  kept  separate  from  the  rest  until  the  examination  has  been  com- 
pleted. But  if  the  injuries  are  of  small  extent,  and  there  seems  to  be 
no  fecal  extravasation  from  the  wrounds,  they  should  be  closed  at  once 
according  to  the  simple  (and  yet  original)  method  employed  by  Bull1 
in  the  suture  of  gunshot  wounds  of  the  intestine  under  similar  conditions. 

The  injured  loop  is  carefully  laid  upon  a  large  flat  sponge,  and 
steadied  there  by  an  assistant  who  holds  the  mesentery  and  avoids  all 
pressure  upon  the  gut  itself,  while  the  operator  carefully  picks  up  the 
wall  of  the  intestine  with  mouse-tooth  forceps  and  inserts  the  Lembert 
sutures,  tying  each  one  as  soon  as  inserted.  The  needle  preferred  by 
Dr.  Bull  is  the  delicate,  curved  intestinal  needle  of  Schramm.  Fecal 
extravasation  is  avoided  by  the  extremely  careful  handling  of  the  gut, 
and  the  edges  of  the  wound  remain  unsoiled,  a  great  improvement  on 
the  ordinary  method  of  removing  the  feces  from  the  neighborhood  of  the 
wound  by  pressure  upon  the  gut  before  the  sutures  are  inserted,  for  it  is 
almost  impossible  to  do  this  without  the  escape  of  a  small  quantity,  and 
the  contamination  of  the  edges  of  the  wound. 

All  the  intestines  having  been  inspected,  and  all  injuries  treated  at 
once  or  laid  aside  for  later  treatment,  the  peritoneal  cavity  is  to  be  thor- 
oughly cleansed  with  sponges.  If  there  has  been  a  rupture  of  the  intes- 
tine, even  if  it  is  very  small,  and  even  if  there  has  been  no  perceptible 
fecal  extravasation,  the  whole  cavity  must  be  flushed  with  a  1  to  10,000 
bichloride,  or  a  1  to  100  carbolic  acid  solution,  at  the  temperature  of  the 
blood,  or  warmer.  Still  better  would  be  plain  water  which  had  been 
kept  boiling  for  at  least  an  hour  and  then  allowed  to  cool  off,  or  cooled 
by  the  addition  of  cold  water  which  had  been  previously  boiled  in  the 
same  way.  A  large  quantity  of  water  must  be  used,  the  cavity  being 
filled  and  emptied  several  times.  The  warm  water  will  be  found  to  im- 
prove the  condition  of  the  patient,  and,  therefore,  collapse  is  no  contra- 
indication to  this  flushing  out  of  the  belly. 

The  cavity  having  been  cleaned,  those  portions  of  the  intestine  which 
are  uninjured,  or  have  been  already  treated,  should  also  be  thoroughly 
douched  with  the  water,  and,  if  much  feces  has  escaped,  should  be  well 
scrubbed  with  sponges.    In  cleaning  the  intestine,  great  care  and  many 


1  The  author  is  indebted  to  Dr.  Bull  for  permission  to  describe  this  method. 


348 


CURTIS,  RUPTURE  OF   THE  INTESTINE. 


sponges  will  be  necessary  to  prevent  the  fluid  from  running  down  the 
funnel  formed  by  the  mesentery,  into  the  belly,  which  has  just  been 
cleaned.  All  these  parts  of  the  intestine  can  then  be  returned  to  the 
abdomen,  only  the  loops  still  untreated  being  kept  out.  When  exces- 
sive distention  of  the  gut  by  gas  interferes  with  its  return  to  the  belly, 
punctures  may  be  made  with  a  coarse  aspirating  needle,  if  care  is  taken 
to  avoid  escape  of  feces,  and  the  punctures  are  closed  by  a  couple  of 
Lembert  sutures  to  prevent  subsequent  leakage.  If  the  large  intestine 
be  distended,  a  long  flexible  tube  may  be  inserted  into  the  rectum,  and 
by  manipulation  through  the  walls  of  the  gut  it  can  be  easily  carried  up 
beyond  the  sharp  bends  in  the  sigmoid  flexure  which  usually  impede  its 
advance,  and  the  entire  colon  thus  emptied  of  gas. 

We  have  seen  that  there  are  three  varieties  of  injury  to  the  intestine 
to  be  expected,  deprivation  of  blood-supply  by  injury  of  the  mesentery, 
contusion  or  laceration  of  part  of  the  coats  of  the  gut,  and  rupture  of  all 
the  coats  for  the  whole  or  part  of  the  circumference  of  the  bowel.  If 
the  blood  supply  has  been  hopelessly  destroyed  in  any  part  and  gan- 
grene is  inevitable,  that  part  must  be  removed.  If  the  injury  to  the  in- 
testine is  merely  a  laceration  of  part  of  its  coat,  or  a  contusion,  suture 
will  be  necessary  if  the  laceration  involves  more  than  the  peritoneum, 
the  injured  spot  being  simply  turned  into  the  lumen  of  the  gut  and  the 
folds  thus  made  in  the  w7all  united  over  it  by  the  Lembert  suture.  In 
these  lacerations,  the  peritoneal,  and  even  the  deeper  coats,  are  some- 
times stripped  off  for  a  considerable  extent,  and  resection  of  the  injured 
part  may  be  necessary. 

The  small  ruptures  will  often  allow  of  suture  without  resection,  like 
bullet-wounds  of  the  gut,  the  more  so,  that  these  ruptures  do  not  often 
involve  the  mesenteric  border,  and  hence  do  not  interfere  with  the 
blood  supply.  Of  intestinal  resection  and  suture  we  need  not  speak 
further. 

It  is  probable  that  the  creation  of  an  artificial  anus  will  be  the  opera- 
tion best  suited  to  most  cases  of  rupture  of  intestine  in  contusion  of  the 
abdomen.  The  collapse  of  the  early  stages,  and  the  exhaustion  later 
(when  it  has  been  impossible  to  make  an  early  diagnosis)  will  in  the 
great  majority  of  cases  prevent  any  attempt  at  such  a  prolonged  opera- 
tion as  resection  of  the  intestine  with  suture,  and  the  latter  should  be 
reserved  for  the  most  favorable  cases.  It  will  be  easy  to  restore  the 
continuity  of  the  gut  at  some  later  time  when  the  patient  has  recovered 
from  the  accident,  and  the  dread  of  having  a  permanent  fecal  fistula 
need  not  be  allowed  to  weigh  in  the  decision  of  the  matter. 

In  making  an  artificial  anus  in  these  cases,  both  ends  of  the  gut  are 
to  be  occluded  with  ligatures  or  clamps,  and  as  it  will  not  be  necessary 
to  empty  the  gut  at  once,  these  may  be  left  in  place  for  twenty-four 
hours  or  longer,  to  allow  adhesions  to  form  and  granulations  to  spring 
up,  thus  avoiding  all  danger  of  infection  by  escaping  feces. 


CURTIS,  RUPTURE  OF  THE  INTESTINE. 


349 


The  creation  of  an  artificial  anus  will  greatly  shorten  the  duration  of 
a  laparotomy  for  rupture  of  the  intestine,  and  should  be  used  in  every 
case  in  which  the  patient's  strength  is  doubtful.  The  operation  admits 
of  still  greater  abbreviation,  if  the  jDatient  is  in  a  desperate  condition,  by 
securing  the  ends  of  the  gut  with  a  clamp  or  ligature,  thoroughly  clean- 
ing the  peritoneal  cavity,  passing  the  deep  sutures  for  the  abdominal 
wound  further  back  from  the  edge  than  usual,  in  order  to  evert  more 
peritoneum  and  make  a  broader  peritoneal  surface,  and  trusting  to  the 
pressure  of  these  sutures,  together  with  the  aid  of  the  clamp  or  ligature 
to  hold  the  ends  of  the  gut  in  place  until  the  adhesions  are  firm.  The 
entire  operation  performed  in  this  way  ought  not  to  last  more  than  half 
an  hour,  and  would  not  be  too  much  to  attempt  unless  evidently  fatal 
collapse  had  set  in. 

In  performing  laparotomy  for  supposed  rupture  of  the  intestine,  the 
surgeon  must  be  prepared  to  deal  with  any  injury  to  the  other  abdom- 
inal organs.  Eupture  of  the  stomach  would  be  treated  on  a  similar 
plan  to  rupture  of  the  gut.  Rupture  of  the  bladder  would  also  be 
amenable  to  suture.  In  rupture  of  the  liver,  spleen,  or  kidney,  it  would 
be  necessary  first  to  control  the  hemorrhage — by  ligature,  deep  sutures, 
the  cautery,  or  pressure  by  a  tampon  of  iodoform  gauze.  The  spleen  or 
kidney  could  be  removed.  It  is  certain  that  great  triumphs  await  the 
surgery  of  the  future  in  the  treatment  of  these  formidable  injuries. 

Undoubtedly  in  many  cases  of  rupture  of  the  intestine  the  patient 
will  be  too  weak  to  permit  of  any  operation,  for  it  is  certainly  not  jus- 
tifiable to  perform  laparotomy  when  the  patient  is  in  collapse.  This 
has  already  been  done  too  often,  as  may  be  seen  by  the  cases  reported. 
Nothing  is  gained  by  such  operations,  and  they  bring  discredit  upon  the 
surgeon  and  his  art.  If  the  patient  is  so  feeble  that  it  is  impossible  to 
bring  about  an  improvement  by  the  ordinary  stimulants,  he  will  cer- 
tainly not  survive  laparotomy. 

We  may  sum  up  the  practical  results  of  our  inquiry  in  the  following : 

Conclusions. — 1.  The  treatment  of  contusion  of  the  abdomen  should 
be  purely  expectant  in  the  early  stage,  until  symptoms  of  internal  injury 
have  appeared,  or  until  the  full  extent  of  time  in  which  they  may  be 
expected  has  passed.  Explorative  laparotomy  at  this  time  is  inad- 
missible. 

2.  When  svmptoms  of  uncontrollable  internal  hemorrhage,  or  serious 
visceral  injury  appear,  laparotomy  is  indicated  ;  but,  when  the  diagnosis 
is  uncertain,  the  operation  should  always  be  begun  as  an  exploration. 

3.  Great  collapse  is  an  absolute  contraindication  to  all  operative  in- 
terference. 

4.  When  rupture  of  the  intestine  is  found,  the  best  method  of  treat- 
ment is  to  secure  the  injured  gut  in  the  abdominal  wound,  and  form  an 
artificial  anus.  This  can  be  easily  relieved  by  a  later  operation,  when 
the  patient  has  recovered  his  strength. 


350      HOWARD,   HEPATIC   CIRRHOSIS  IN  CHILDREN. 


ON  HEPATIC  CIRRHOSIS  IN  CHILDREN.1 
By  R.  Palmer  Howard,  M.D.,  L.R.C.S.  Ed.,  LL.D.; 

PROFESSOR  OF  MEDICINE  IN  MCGILL  UNIVERSITY,  MONTREAL. 

Having  met  with  two  cases  of  that  rare  affection  in  children,  cirrhosis 
of  the  liver,  I  venture  to  make  them  the  subject  of  a  few  observations ; 
not  that  I  hope  to  remove  the  obscurity  which  surrounds  the  subject,  but 
rather  to  add  to  the  few  examples  already  recorded  two  more,  in  which 
neither  the  use  of  alcohol  nor  the  virus  of  syphilis  can  be  assigned  as 
the  cause  of  the  hepatic  cirrhosis. 

The  infrequency  of  cirrhosis  of  the  liver  in  children  may  be  substan- 
tiated by  a  few  quotations.  Thierfelder2  speaks  "  of  the  absolute  rarity  of 
the  affection  as  regards  children."  Henoch3  admits  that  he  never  found 
the  disease  "  fully  developed  in  children."  Dr.  Charles  West4  states  that 
"  an  experience  of  70,000  cases  of  children's  disease  had  yielded  him  but 
four  examples  of  hepatic  cirrhosis."  The  late  lamented  Flint,  in  a  pri- 
vate letter  to  me  respecting  one  of  the  cases  about  to  be  reported,  dated 
December,  1884,  remarks  that  "  in  so  young  a  subject  the  disease  is 
exceedingly  rare."  And  Neureuter5  estimates  its  ratio  to  other  diseases 
admitted  into  the  Franz  Joseph  Hospital  for  children  at  one-tenth  of 
one  per  cent. 

I  will  first  relate  the  two  cases  that  have  been  under  my  own  care. 

Case  I. — Miss  ,  aged  nine  years,  was  brought  to  me  in  Novem- 
ber, 1878,  on  account  of  a  few  nsevoid-looking  groups  of  vessels  on  the 
right  eyelid,  which  had  formed,  her  mother  thought,  since  a  severe 
attack  of  pertussis  experienced  in  the  preceding  July.  On  January  27, 
1879,  my  services  were  again  sought,  because  the  child  had  been  "poorly 
for  some  weeks."  It  was  subsequently  admitted  that  she  had  not  been 
well  for  several  months.  She  had  been  weak,  fretful,  nervous,  and 
unable  to  perform  her  school-work,  and  her  appetite  had  failed.  Her 
leading  symptoms  at  this  first  visit  were  a  subicteroid  tint  of  skin  and 
conjunctiva,  and  enlarged  liver,  its  lower  margin  extending  an  inch  and 
a  half  below  the  ribs ;  the  spleen  also  in  the  same  condition,  and  its  lower 
end  perceptible  two  inches  below  the  ribs.  The  upper  abdominal  zone  wTas 
very  perceptibly  enlarged ;  indeed,  her  mother  had  for  some  time  thought 
the  child's  waist  increased  in  circumference.  Pulse  114;  temperature 
1034°  F. ;  tongue  clean;  urine  of  deep  orange  color;  a  loose  cough,  not 
explained  by  examination  of  chest,  the  organs  in  which  were  normal,  so 
far  as  physical  signs  could  be  relied  on.  Expectoration  scanty,  semi- 
transparent,  viscid,  ?nd  pink  from  the  presence  of  a  minute  quantity  of 
blood. 

1  Read  at  the  meeting  of  the  Association  of  American  Physicians,  Washington,  June  2,  1887. 

2  Ziems3en's  Cyclopedia,  ix.  p.  175.  3  Lectures  on  Diseases  of  Children,  1882,  p.  232. 

4  Diseases  of  Infancy  and  Childhood,  7th  ed.,  p.  654. 

5  Oesterreichisches  Jahr.  fiir  Paediatrik,  1877,  viii. 


HOWARD,  HEPATIC  CIRRHOSIS   IN  CHILDREN. 


351 


Personal  history.  Is  one  of  four  children ;  all  of  whom  are  living 
and  healthy,  except  a  brother,  who  died  of  membranous  laryngitis  at 
five.  All  the  four  children  have  had  symmetrical,  handsome  faces  and 
figures,  devoid  of  evidence  of  rickets,  hereditary  syphilis,  or  scrofula.  The 
patient  has  always  been  healthy,  and  made  good  recoveries  from  measles, 
croup,  chickenpox,  and  whooping-cough.    She  had  escaped  scarlatina. 

Family  history.  Mother  is  remarkably  healthy  and  well  nourished. 
Mother's  father  died  of  valvular  disease ;  mother's  mother  of  disease  of 
kidney  ;  a  maternal  uncle  of  phthisis,  and  a  maternal  aunt  of  laryngeal 
diphtheria ;  another  maternal  aunt  died  of  cerebral  embolism  from  rheu- 
matic valvular  disease,  a  third  from  puerperal  convulsions,  and  a  fourth, 
three  weeks  after  parturition,  from  some  puerperal  inflammation.  Three 
maternal  uncles  and  two  aunts  are  alive,  and  enjoy  good  health. 

The  child's  father,  a  vigorous,  healthy  man,  has  not  had  syphilis,  and 
uses  alcohol  in  moderation.  The  paternal  grandfather  had  always  been 
healthy,  and  died  in  advanced  life  ;  the  paternal  grandmother  died  when 
comparatively  young,  the  cause  of  her  death  is  not  known  ;  all  the  other 
members  of  father's  immediate  family,  viz.,  a  brother  and  two  sisters, 
are  living  and  healthy. 

It  would  occupy  too  much  time,  to  report  the  daily  notes,  and  the  lead- 
ing facts  must  suffice. 

A  febrile  temperature  prevailed  throughout  the  four  months  that  the 
child  lived  after  coming  under  observation.  During  the  first  four  days 
of  February  it  was  104°,  and  for  the  rest  of  the  month  it  ranged  between 
101°  and  100°.  The  average  daily  temperature  for  the  first  fourteen 
days  of  March  was  100.7°,  and  for  the  remainder  of  the  month  about 
99.4°.  For  the  first  week  of  April  the  temperature  ranged  between 
101°  and  100.5°,  for  the  second  week  between  100°  and  9B°,and  for  the 
rest  of  the  month  between  100°  and  98-f  °,  although  it  was  but  three  times 
below  99°.  For  tne  first  half  of  May  it  ranged  between  100°  and  101° ; 
during  the  last  ten  days  of  the  patient's  life  the  temperature  was  not 
recorded. 

Epistaxis  was  frequently  present  throughout  the  illness,  in  moderate 
amount,  yet  sufficient  to  soil  three  handkerchiefs  a  day,  It  had  occurred, 
however,  very  often  since  the  attack  of  whooping-cough  in  July. 

Hemorrhage  from  the  kidneys  was  also  a  persistent  symptom  after  its 
first  appearance  on  February  25th.  The  urine  was  rarely  free  from 
\  blood  after  that  date,  but  the  removal  of  the  pressure  of  the  ascitic  fluid 
by  tapping  was  followed  by  a  temporary  sensible  reduction  in  the  pro- 
portion of  blood  contained  in  the  urine. 

In  the  early  part  of  February  pain  of  the  character  of  "  bellyache  " 
was  experienced  in  the  umbilical  region  for  one  day,  but  it  was  unac- 
companied by  tenderness  on  pressure.  Pain  in  the  splenic  region  was 
complained  of  for  three  days  before  the  first  tapping,  which  was  per- 
formed on  April  7th.  It  did  not  recur  in  that  region  for  three  weeks, 
at  which  time  the  belly  was  rapidly  refilling.  But  the  night  succeeding 
the  first  tapping,  pain  occurred  in  the  right  side  of  abdomen,  and  per- 
sisted for  the  four  succeeding  days  ;  yet  it  was  unaccompanied  by  tender- 
ness, or  a  higher  temperature  than  had  immediately  preceded  the 
paracentesis,  and  the  ascitic  fluid  was  found  to  be  transparent  even  after 
the  third  tapping,  which  became  necessary  a  fortnight  after  the  second. 

From  these  facts  it  may  be  concluded  that  the  turbid  Serum  and  recent 


t 


352      HOWARD,  HEPATIC   CIRRHOSIS  IN  CHILDREN. 


lymph  found  in  the  peritoneal  cavity  after  death,  were  the  products  of 
a  latent  peritonitis  which  succeeded  the  last  paracentesis. 

Perceptible  enlargement  of  a  few  veins  in  the  epigastric  zone,  was 
noted  on  February  10th  ;  by  May  3d  many  large  mammary  veins  were 
found  inosculating  with  these ;  and  by  May  17th  the  thoracic  and 
abdominal  parietes  were  covered  by  numerous  large  veins,  suggestive  of 
the  serious  obstruction  that  existed  in  the  portal  system. 

Ascites  was  first,  noted  on  March  4th.  It  resisted  digitalis,  squill, 
cream  of  tartar,  potassium  iodide,  and  an  occasional  cathartic  or  an 
active  diaphoretic ;  and  tapping  became  necessary  on  April  7th,  when 
nine  pints  of  transparent  citron-colored  serum  were  removed.  The 
operation  was  repeated  on  April  21st,  and,  for  the  third  time,  on  May 
4th,  upon  which  occasion  eleven  pints  were  evacuated. 

A  reduction  in  the  size  of  the  spleen  was  noticed  after  iced  compresses 
had  been  applied  over  the  organ  three  times  a  day  for  thirty  to  forty 
minutes  at  a  time,  but  a  month  afterward  the  organ  had  regained  its 
former  size. 

On  the  26th  of  February,  the  day  after  the  first  occurrence  of  hsema- 
turia,  the  urine  had  a  sp.  gr.  of  1.022,  and  a  smoky  appearance,  but  no 
marked  sediment.  It  contained  about  one-third  by  volume  of  albumen, 
many  leucocytes  and  blood-corpuscles,  very  few  highly  granular  hyaline 
casts,  and  in  the  same  field  a  single  waxy  and  a  single  epithelial  cast. 
The  urine  of  the  5th  of  May  had  a  sp.  gr.  of  1.014;  it  contained  only  one- 
twentieth  of  its  volume  of  albumen.  Numerous  blood  globules,  several 
large  epithelial  cells  containing  numerous  fat  globules  and  a  single 
hyaline  cast,  were  seen  in  one  field. 

On  the  10th  of  April  my  friend,  Dr.  Osier,  counted  the  blood-cor- 
puscles and  reported  2,400,000  red  per  cubic  millimetre,  and  1  white  to 
144  red.  Six  days  later,  with  the  same  proportion  of  red  corpuscles,  the 
ratio  of  the  white  to  the  red  was  1  to  91.  From  the  report  of  the  latter 
date  the  following  memorandum  is  taken :  "  Nothing  of  special  note  about 
the  corpuscles — red  natural,  of  uniform  size  ;  no  microcytes.  Whites  of 
natural  appearance ;  very  little  variation  in  size ;  no  nucleated  red  cor- 
puscles." 

On  the  12th  of  March  a  troublesome  dry  cough  set  in,  accompanied 
by  fine  bubbling  in  the  bases  of  the  lungs  without  thp.  whistling  rhonchi 
of  bronchitis.  About  the  same  time  a  moderate  general  puffiness  of 
hands,  feet,  and  legs  appeared,  symptoms  which,  when  taken  in  connec- 
tion with  the  character  of  the  urine  a  fortnight  before,  probably  indicated 
a  renal  source.  The  state  of  the  kidneys  after  death  favors  this  view. 
During  the  last  eight  or  nine  days  of  life  grave  disturbance  of  the  nervous 
centres  occurred;  delirium,  ravenous  appetite,  tearing  of  bedclothes,  a 
soporose  passing  into  an  unconscious  state.  Next  day  recovery  of  con- 
sciousness, involuntary  evacuations,  reticence  or  actual  inability  to  speak 
(not  established  which),  extremely  dilated  pupils,  twitchings.  Then  a 
half-conscious  condition  attended  with  monotonous  expression,  general 
restlessness,  and  moaning.  Death  took  place  on  the  23d  of  May,  four 
months  from  the  time  that  she  came  under  treatment. 

Autopsy  made  next  day  by  Prof.  Osier.  Eleven  pints  of  turbid  serum 
with  flocculi  of  recent  lymph  in  peritoneal  cavity.  Adhesion  of  great 
omentum  to  intestines.  Parietal  peritoneum  thick  and  granular-look- 
ing, chiefly  in  the  upper  abdominal  zone  and  on  the  diaphragm. 

Spleen  about  three  times  normal  size ;  capsule  thickened ;  texture 


HOWARD,  HEPATIC   CIRRHOSIS   IN    CHILDREN.  353 


tough,  resisted  the  knife.  Liver,  right  lobe  adherent  by  thick  layer  of 
imperfectly  organized  lymph  to  under  surface  of  diaphragm.  The 
organ  was  large  and  thick;  very  granular;  tough,  resisting  the  knife; 
of  a  dirty  white  color ;  very  ansemic — fine  specimen  of  hypertrophic 
cirrhosis.  The  new  fibrous  tissue  extended  throughout  the  entire  organ 
and  appeared  to  be  "  mono-lob ular."  Gall-bladder  contained  a  little  clear 
citron-colored  fluid.    No  gall-stones  or  obstruction  of  the  biliary  ducts. 

A  laminated  colorless  coagulum  within  vena  porta  and  loosely  attached 
to  its  lining  membrane.  Stomach,  suprarenal  capsules,  intestines,  and 
bladder  normal. 

Kidneys  large  and  deeply  congested  ;  cut  surface  coarse;  capsuleeasily 
torn  off ;  a  moderate  serous  effusion  into  right  pleura ;  a  fine  granular 
exudation  over  pleura  covering  lower  lobe  of  right  lung ;  some  clusters  of 
gray  tubercle  in  the  upper  lobe  of  both  lungs  ;  a  caseous  nodule  size  of 
dried  pea  in  left  upper  lobe,  and  a  caseating  bronchial  gland  at  root  of 
right  lung.    Heart,  brain,  and  cord  not  examined. 

Case  II.  occurred  six  years  after  the  first,  in  the  brother  of  the  little 
girl  whose  history  has  just  been  read. 

He  appears  to  have  had  in  previous  years  the  same  diseases  as  his 
sister,  and  like  her  to  have  escaped  scarlatina.  Some  two  years  before 
the  detection  of  the  illness  about  to  be  described,  this  boy,  then  eight 
years  old,  was  brought  to  me  by  his  mother  as  he  looked  pale,  appeared 
not  to  be  thriving,  and  she  feared  that  he  might  be  the  subject  of  the 
same  affection  as  his  deceased  sister.  Nothing  definitely  wrong  was  dis- 
covered at  the  time  by  me,  nor,  a  few  months  later,  by  another  physi- 
cian ;  but  the  child  improved  while  taking  lactopeptin.  In  May,  1884, 
he  was  seen  by  me  on  account  of  a  slight  herpes  circinatus,  and  his  health 
appeared  to  be  good  at  the  time.  The  summer  months  were  spent  at  the 
seaside,  where  he  underwent  a  good  deal  of  fatigue  without  apparent  ill 
effect.  For  a  fortnight  after  returning  home  he  appeared  to  be  in  good 
health,  but  at  the  end  of  that  period  he  became  languid  and  unfit 
for  work  or  play.  I  was  then  (12th  of  September,  1884)  requested  to 
see  the  child,  and  noted  the  following :  subicteroid  hue  of  skin  and  of 
the  conjunctiva?;  urine  deeply  bile-tinged ;  stools  contained  bile;  waist 
appeared  enlarged  and  epigastric  zone  prominent.  Hepatic  dulness  ex- 
tended from  fifth  space  to  over  a  couple  of  inches  below  the  margin  of  ribs 
in  the  nipple  line  and  well  down  into  the  epigastrium  in  the  median  line. 
The  splenic  dulness  also  much  increased.  Two  small  patches  of  enlarged 
venules  under  left  eye  and  one  upon  side  of  the  neck  were  present  and  of 
a  bright  red  color,  and  exactly  like  those  observed  on  his  sister.  No 
enlarged  lymphatic  glands,  although  twelve  or  eighteen  months  before 
a  single  gland  in  one  groin  was  somewhat  hypertrophied. 

As  in  the  first  case,  a  febrile  temperature  was  present.  During  the 
first  month  it  ranged  between  99f  °  F.  and  100f°  F.,  and  during  the 
second  between  100°  and  101°  in  the  forenoon.  It  did  not  exceed  the 
latter  point  at  any  time  beyond  half  a  degree. 

The  pulse-rate  was  lower  than  in  the  firs  case.  It  did  not  pass  90 
till  the  middle  of  October.  It  gradually  rose  to  104  in  the  succeeding 
month,  and  reached  108  to  110  during  the  last  week  of  life. 

The  liver  and  spleen  enlarged  rapidly,  and  in  a  month  from  the  first 
examination  their  lower  borders  reached  the  horizontal  level  of  the  um- 
bilicus. As  in  the  previous  case,  the  dimensions  of  the  spleen  subse- 
quently became  reduced,  so  that  after  the  first  tapping  its  lower  border 

NO.  CLXXXVIII. — OCTOBBR,  1887.  23 


354     HOWARD,  HEPATIC   CIRRHOSIS   IN  CHILDREN. 


was  only  about  on  a  line  with  the  margin  of  the  left  hypochondrium.  It 
was  found,  however,  an  inch  lower  nine  days  later,  after  the  second  tap- 
ping. The  liver  also  suffered  a  reduction  in  volume ;  for  by  the  5th  of 
December  its  lower  edge  was  only  two  inches  below  the  margin  of  the 
hypochondrium,  instead  of  reaching  to  the  level  of  the  umbilicus. 

Epistaxis  set  in  early  in  September  and  recurred  several  times,  but 
only  in  small  quantities.  Hematuria  was  not  observed,  and  only  once, 
on  the  19th  of  December,  did  blood  appear  in  the  vomited  matters,  and 
then  the  amount  was  trifling.  Jaundice  was  present  when  the  child  first 
came  under  my  care,  and  deepened  with  the  advance  of  the  case.  The 
urine  was  always  deeply  bile-stained,  but  the  stools  were  never  devoid 
of  bile. 

The  blood  was  examined  but  once  (the  11th  of  October).  It  con- 
tained no  excess  of  white  corpuscles  and  was  of  a  deep  red  color. 

The  existence  of  ascites  was  established  on  the  26th  of  November,  and 
it  increased  so  rapidly  that  the  fluid  required  to  be  drawn  off  on  the 
6th  of  December,  when  five  pints  of  transparent  citron-colored  serum  were 
evacuated  by  means  of  an  aspirator.  A  second  tapping  became  neces- 
sary nine  days  after  the  first.    The  fluid  had  its  former  character. 

OEdema  appeared  in  the  feet  and  legs  on  the  12th  of  December,  and 
reached  the  scrotum  and  lower  part  of  trunk  on  the  14th.  The  disten- 
tion of  the  scrotum  became  so  considerable  that  on  the  19th  three  or 
four  needle  punctures  were  made  and  the  oedema  permanently  relieved 
thereby. 

Numerous  large  veins,  branches  of  the  epigastric  and  mammary,  were 
present  in  November,  but  they  did  not  attain  in  either  number  or  size 
the  proportions  observed  in  the  previous  case. 

Pain,  chiefly  in  the  epigastrium  and  over  the  splenic  region  was  first 
complained  of  on  November  22d ;  it  was  unaccompanied  by  tenderness 
on  pressure.  It  persisted  about  eight  days  and  was  very  severe  on  the 
30th  of  that  month.  After  that  the  child  frequently  complained  of 
pain  in  the  belly  which  at  the  time  I  attributed  to  the  distention  of  the 
abdomen. 

On  the  21st  of  December  a  peculiar  delirium,  attended  by  screaming 
and  violent  shaking  of  the  hands,  set  in,  and  lasted  about  three  hours. 
The  same  thing  occurred  on  the  23d,  and  early  on  the  24th,  and  lasted 
about  the  same  time.  Coma  supervened  at  10  A.  m.  of  the  24th.  The 
respiration  was  slightly  stertorous,  with  flapping  of  the  cheeks  ;  the 
pupils  were  widely  dilated,  but  contracted  on  first  exposure  to  light  and 
then  became  as  large  as  before.  There  were  frequent  tetanic  spasms  of  the 
extensors  fixing  the  forearm  in  rigid  extension ;  rigidity  of  the  lower 
limbs,  the  feet  being  rigidly  extended  upon  the  legs,  and  occasionally 
twitching  of  the  eyelids.  Death  took  place  at  2  p.  m.,  four  hours  after 
the  advent  of  the  coma. 

Autopsy,  twenty-five  hours  after  death ;  cold  weather.  No  cada- 
veric rigidity.  Icteroid  hue  of  general  integument.  Five  pints  of 
orange-colored  transparent  serum,  devoid  of  lymph  flakes,  in  peritoneal 
cavity.  No  signs  of  acute  or  chronic  peritonitis.  Liver,  two  and  a 
half  pounds,  enlarged ;  left  lobe  very  broad  vertically,  right  lobe  also 
large  and  its  posterior  border  very  thick,  the  edges  of  anterior  border 
thin;  no  adhesions  of  liver  to  adjacent  parts.  Its  surface  everywhere 
presented  the  typical  "  hob-nail "  appearance.  A  shallow  depression, 
about  equal  in  area  to  that  of  a  man's  palm,  was  seen  about  the  centre  of 


HOWAED,  HEPATIC   CIRRHOSIS   IN  CHILDREN.  355 

its  convex  surface  and  the  granulations  over  this  depression  were  very 
closely  set.  The  substance  was  dense,  resisted  cutting  very  markedly,  and 
was  of  a  deep  yellow  color.  Gall-bladder  full  of  bile  but  not  over  dis- 
tended.   No  gall  stones  present.    Common  duct  pervious. 

Spleen  enlarged  three  or  four  times  its  proper  size,  not  adherent  to 
adjacent  structures,  and  like  the  liver,  free  from  opaque  or  thickened 
patches  on  its  exterior.  Substance  firm,  cut  surface  coarse-looking  and 
exhibiting  some  dark,  purple  areas.  The  peritoneum  and  exterior  of 
intestines  normal.  Right  lung  not  consolidated.  Left  lung,  kidneys, 
heart,  and  brain  not  examined.  My  notes  of  the  autopsy  contain  no 
mention  of  tubercle  in  the  right  lung ;  had  any  been  present  I  doubtless 
would  have  recorded  their  presence. 

Dr.  Wyatt  Johnston,  Demonstrator  of  Pathology  in  McGill  Univer- 
sity, has  kindly  given  the  following  summary  of  the  microscopical 
appearances  of  this  liver.  "  The  fibrous  tissue  is  seen  to  be  developed 
in  connection  with  the  portal  system  and  surrounds  the  acini,  which 
vary  greatly  in  size  and  are  nowhere  very  large.  Where  the  fibrous 
tissue  penetrates  the  acini  it  does  so  as  a  considerable  bundle  and  not  in 
fine  intercellular  filaments*.  The  centres  of  lobules  are  free  from  fibrous 
tissue  ;  central  veins  not  dilated  ;  bile  ducts  look  natural.  In  the  liver 
cells  the  nuclei  do  not  stain  deeply.  This  is  owing,  no  doubt,  to  the  long 
maceration  in  weak  spirit,  and  to  the  same  fact  is  probably  due  the 
apparent  absence  of  small,  embryonic,  fibrous  tissue  cells  at  the  border 
of  the  fibrous  tissue." 

Before  making  a  few  observations  on  the  subject  of  cirrhosis  of  the 
liver  it  may  be  well  to  say  that  by  that  term  is  meant,  in  this  paper,  a 
diffuse  development  of  the  connective  tissue  of  the  liver  without  reference 
to  the  question  of  the  inflammatory  or  the  simple  hypertrophic  nature 
of  that  development.  The  word  interstitial  hepatitis  is  employed  as 
synonymous  with  hepatic  cirrhosis. 

The  known  conditions  in  the  human  subject  under  which  interstitial 
hepatitis  occurs  are  somewhat  numerous  and  may  be  thus  classified  or 
grouped : 

1.  Toxic  or  irritating  substances  entering  the  blood  ;  (a)  especially 
alcohol,  (6)  syphilitic  virus,  (c)  malaria,  (d)  probably,  but  rarely,  lithic 
acid  when  productive  of  the  lithic  acid  or  gouty  dyscrasia,1  (e)  blood 
pigment  in  diabetes.2 

2.  Chronic  congestion  of  the  hepatic  vein,  as  in  valvular  and  pulmonary 
diseases,  and  in  those  rare  affections  of  which  I  have  seen  examples, 
obstruction  or  obliteration  of  the  hepatic  veins,  or  of  the  inferior  vena 
cava  above  entrance  of  the  hepatic  vein. 

3.  Adhesive  inflammation  of  the  portal  vein  (pylephlebitis^,  especially 
the  syphilitic  variety,  three  cases  of  which  I  have  found  reported. 

1  Thierfelder  doubts  this,  but  Murchison  maintains  it  from  his  own  observation  :  Diseases  of  Liver, 
3d  ed.,  p.  636,  1885. 

2  Hanot:  Arch,  de  Phys.  Normal  et  Path.,  Paris,  3  s.  vii.  50-87,  and  Latulle  :  No.  20,  Bull,  et  Mem. 
de  la  Soc.  Med.  des  Hopitaux. 


356 


HOWARD,  HEPATIC 


CIRRHOSIS 


IN  CHILDREN. 


4.  Extension  of  inflammation  to  the  interstitial  tissue  of  the  liver  in 
chronic  peritonitis,  and  in  perihepatitis. 

5.  Obstruction  of  bile  ducts,  whether  from  congenital  defects  (absence 
of  common  duct)  or  from  post-congenital  disease  (tumors,  gall-stones,  or 
experiment  ligatures). 

6.  In  association  with  tubercular  disease,  more  especially  of  the 
lungs. 

7.  As  part  of  a  general  tendency  to  new  formation  or  hypertrophy  of 
connective  tissue  in  the  system,  the  so-called  fibroid  diathesis. 

I  have  not  had  time  or  opportunity  to  institute  a  very  extensive 
search  into  the  literature  of  the  subject,  but  have  collected  sixty-one 
cases  of  cirrhosis  of  the  liver  in  children  up  to  the  age  of  puberty,  which, 
with  two  personal  cases,  give  an  aggregate  of  sixty-three. 

It  seemed  to  me  best  thus  to  limit  the  age  rather  than  include  cases 
even  of  young  adults,  for  in  the  latter  the  influence  of  alcohol  would 
probably  be  found  to  be  a  dominant  one  as  it  is  in  persons  of  middle 
age.  I  have  also  excluded  cases  of  hepatic  cirrhosis  due  to  congenital 
defects  of  the  biliary  ducts.  Confining  our  attention  for  the  present  to 
the  causative  relations  of  these  sixty-three  cases,  some  interesting  facts  are 
brought  out. 

In  the  first  place,  the  above  mentioned  conditions  under  which  cir- 
rhosis of  the  liver  is  known  to  occur  were  alleged  to  be  present  in  but 
thirty  out  of  the  sixty-three  cases,  leaving  over  one-half  of  these  to  be 
accounted  for. 

1.  The  ordinary  cause  of  the  disease  in  adults,  the  excessive  use  of 
alcohol,  existed  in  only  10  of  these  cases  of  cirrhosis  in  children.  Its 
absence  was  noted  47  times,  and  no  mention  was  made  of  it  in  6  cases. 

2.  A  heredito-syphilitic  origin  obtained  in  7  cases,  the  cirrhosis  exist- 
ing at  birth  in  all  but  one,  a  boy  sixteen  years  of  age.  One  of  these 
children  was  born  in  the  thirtieth  week  of  gestation,  and  another  in  the 
thirty-fourth  week.  The  absence  of  syphilitic  causation  was  affirmed 
in  29  cases,  and  no  mention  was  made  of  it  in  30  cases. 

3.  In  3  of  the  syphilitic  cases  the  virus  set  up  an  adhesive  peripyle- 
phlebitis  Avhich  terminated  in  a  diffuse  interstitial  hepatitis,  and  these 
are  the  only  instances  in  the  whole  number  of  cases  of  hepatic  cirrhosis 
in  children  in  which  adhesive  inflammation  of  the  portal  vein  was  the 
starting  point  of  the  process. 

4.  Venous  congestion  of  the  liver,  a  not  infrequent  factor  in  the  produc- 
tion of  cirrhosis  in  the  adult,  existed  in  but  a  solitary  case.  The  con- 
dition present,  obliteration  of  the  hepatic  vein  close  to  the  vena  cava, 
is  exceedingly  rare  at  all  periods  of  life.  I  have  seen  one  example 
of  it. 

5.  The  lithic  acid  diathesis  is  not  once  mentioned  as  having  been 
present  in  these  cases  ;  and 


HOWARD,  HEPATIC  CIRRHOSIS   IN    CHILDREN.  357 

6.  The  same  is  true  of  malaria  and  ague.  The  absence  of  malarial 
influence,  however,  is  only  affirmed  seven  times  ;  it  may  often  have  been 
overlooked. 

7.  In  a  single  case  the  existence  of  widespread  false  membrane  in 
all  parts  of  the  abdomen  and  a  complete  envelope  of  it  enclosing  the 
liver,  suggest  that  peritonitis  may  have  extended  to  the  capsule  of  the 
liver  and  excited  the  interstitial  hepatitis.  In  another  case  there  were 
numerous  adhesions  between  the  liver  and  surrounding  parts,  but  no 
general  peritonitis. 

8.  The  association  of  hepatic  cirrhosis  with  tuberculous  disease  obtained 
in  7  of  these  collected  cases,  perhaps  in  8 ;  about  the  same  proportion 
as  that  in  which  cirrhosis  and  syphilis  were  coexistent. 

9.  There  are  recorded  examples  in  the  adult  of  the  existence  of 
cirrhosis  of  the  liver  along  with  a  tendency  to  a  condition  of  general 
fibrosis  in  the  system. 

In  two  cases,  two  organs,  the  liver  and  kidneys,  were  cirrhosed ;  and  in 
two,  three  organs  had  undergone  chronic  interstitial  fibroid  alterations. 
Thus,  in  one  the  child  had  taken  a  great  deal  of  wine  between  meals  and 
the  liver  was  typically  cirrhosed,  the  spleen  large  and  firm,  and  the 
mucous  membrane  of  the  stomach  thickened.  Again,  a  girl  of  thirteen, 
without  a  history  of  intemperance,  had,  together  with  extreme  hepatic 
cirrhosis,  evidences  of  old  double  pleurisy  and  old  peritonitis.  Another 
is  that  of  an  infant  that  died  at  birth,  free  from  a  syphilitic  history,  in 
which  Virchow  found  cirrhotic  changes  in  the  liver,  spleen,  and  kidneys 
coexisting  with  peritonitis.  But  the  most  striking  instance  of  a  general 
tendency  to  overgrowth  of  connective  tissue  is  afforded  by  the  case  of  a 
girl  aged  six,  who  occasionally  "  took  beer  at  dinner,  but  did  not  like  it," 
and  in  whom,  in  addition  to  cirrhosis  of  the  liver,  there  was  hyper- 
trophy of  the  connective  tissue,  and  an  infiltration  of  small  round  cells 
in  the  spleen,  kidneys,  stomach,  heart,  and  brain.  The  walls  of  the 
bloodvessels  in  all  the  organs  were  also  thicker  than  natural. 

In  only  six  then  of  the  fifty-seven  examples  of  non-syphilitic  cirrhosis 
of  the  liver  in  children,  omitting  those  in  which  the  liver  and  spleen, 
but  no  third  organ,  had  undergone  cirrhotic  changes,  can  it  be  said  that 
the  hepatic  cirrhosis  was  the  outcome  of  a  general  tendency  of  the 
system  to  fibrosis;  and  in  only  one  of  them  was  found  such  a  thicken- 
ing of  the  walls  of  the  bloodvessels  as  would  justify  the  application 
of  Gull  and  Sutton's  theory  of  an  arterio-capillary  fibrosis  as  the  source 
of  hepatic  cirrhosis,  at  least  in  children.  It  is,  however,  to  be  borne 
in  mind,  that  the  condition  of  the  vascular  system  lias  very  probably 
not  often  been  investigated  in  this  affection  in  childhood. 

The  instances  in  which  a  firm  or  tough  condition  of  the  spleen 
occurred  in  association  with  cirrhosis  of  the  liver,  other  organs  escaping 
such  alterations,  have  not  been  included  in  the  above  illustrations  of  a 


358     HOWARD,   HEPATIC   CIRRHOSIS   IN  CHILDREN. 

more  or  less  general  tendency  to  fibrosis,  because  the  splenic  alterations 
are  reasonably  explicable  upon  other  grounds,  such  as  habitual  over- 
stimulation of  the  spleen  by  passive  congestion  of  its  structure  with 
portal  blood,  the  blood,  moreover,  probably  containing  products  irritat- 
ing to  that  viscus.  But  it  is  only  right  to  say  that  in  thirteen  instances, 
along  with  the  hepatic  cirrhosis,  the  spleen  was  found  large  and  firm  ; 
and  in  two  instances  tough.  In  eight  instances  it  is  simply  called 
"  large,"  and  in  one  "  large  and  soft."  It  may  be  said  that  in  twenty- 
four  of  the  fifty-seven  cases  of  the  non-syphilitic  group  the  spleen  was 
abnormal. 

Assuming  that  we  have  so  far  determined  the  causative  relation  of 
about  one-half  of  these  sixty  odd  cases  of  hepatic  cirrhosis  in  children, 
what  about  the  other  half?  Before  attempting  an  answer  to  this  ques- 
tion it  will  be  well  to  recall  the  fact  that  in  addition  to  the  above  men- 
tioned well-established  conditions  under  which  interstitial  hepatitis 
occurs,  there  are  others  which  have  been  suggested,  but  which  need 
much  investigation  and  corroboration  before  they  can  be  accepted  as 
proven,  however  probable  they  may  appear  both  from  analogy  and  fact. 
George  Budd,1  over  forty  years  ago,  suggested  that  "  there  may  be  other 
substances  among  the  immense  variety  of  matters  taken  into  the  stomach, 
or  among  the  products  of  faulty  digestion,  which,  on  being  absorbed 
into  the  portal  blood,  cause,  like  alcohol,  adhesive  inflammation  of  the 
liver."  Much  more  recently,  in  1872,  Botkin2  advanced  the  hypothesis, 
that  the  acute  infectious  diseases  may  originate  chronic  inflammatory 
processes  in  the  parenchymatous  organs,  because  he  had  found  in  a 
number  of  cases  commencing  interstitial  inflammation  of  the  liver  in 
persons  dying  of  cholera  or  of  typhoid  fever.  And  Klein,  in  1877/ 
described  an  acute  interstitial  hepatitis  as  present  in  eight  cases  of  scar- 
latina which  he  had  examined. 

Now,  although,  so  far  as  I  am  aware,  no  instance  has  been  recorded 
in  which  cirrhosis  of  the  liver  was  shown  to  be  a  direct  sequence  of 
scarlatina,  cholera,  or  typhoid  fever,  yet,  as  it  is  established  that  in  the 
kidney  the  poison  of  scarlet  fever  does  frequently  set  up  acute  inflam- 
mation of  the  parenchyma  and  interstitial  tissue  which  often  becomes 
chronic,  why  may  not  the  liver  occasionally  suffer  a  similar  chronic 
inflammatory  process  ?  and  what  support  is  afforded  to  that  view  by  this 
collection  of  cases?  An  analysis  of  the  thirty-eight  instances  of  cir- 
rhosis of  the  liver  contained  in  these  tables,  which  cannot  be  referred  to 
any  of  the  established  causes  of  that  affection,  shows  that  in  nine 
instances  the  following  acute  infectious  diseases  preceded  by  a  longer  or 
shorter  interval  the  cirrhosis  ;  viz.,  scarlatina  twice,  measles  and  scarla- 


1  Diseases  of  Liver,  1845. 

3  Path.  Soc.  Trans.,  xxviii.  439. 


2  Quoted  by  Thierfelder  in  Ziemssen's  Cyclop.,  ix. 


HOWARD,  HEPATIC   CIRRHOSIS   IN   CHILDREN.  359 

tina  once,  measles  alone  four  times,  measles  and  pertussis  thrice.  In 
twenty-five  instances  no  mention  is  made  of  acute  infectious  diseases 
as  antecedent  to  the  cirrhosis,  and  they  were  absent  in  three.  The  rela- 
tive frequency  of  measles  and  of  scarlatina  in  the  above-mentioned  nine 
cases  was  as  8  to  3 ;  rickets  once  preceded  the  cirrhosis. 

When  the  frequency  with  which  the  acute  infectious  diseases  occur  in 
childhood  is  borne  in  mind,  it  is  plain  that  the  above  statements  cannot 
be  said  to  establish  Botkin's  hypothesis.  Certainly,  the  infrequency 
with  which  hepatic  cirrhosis  obtains  in  children  who  have  gone  through 
the  common  infectious  fevers  is  quite  in  contrast  to  the  comparative  fre- 
quency with  which  chronic  nephritis  follows  scarlatina,  and  we  need 
much  stronger  evidence  than  has  been  adduced  to  prove  that  the  acute 
infectious  fevers  are  causes  of  hepatic  cirrhosis  in  children.  However, 
an  exception  is  admitted  as  already  mentioned,  in  favor  of  intermittent 
fever  or  of  malaria. 

Even  if  it  be  granted  that  in  the  nine  cases  in  which  acute  infectious 
fevers  did  precede  the  hepatic  cirrhosis  they  really  originated  the  inter- 
stitial lesion,  there  remain  three  in  which  those  fevers  had  not  occurred, 
and  twenty-five  in  which  no  mention  is  made  of  them  as  having  existed. 
For  such  examples  of  hepatic  cirrhosis  Budd's  explanation  is  available 
and  appears  highly  probable.  Indeed,  it  is  more  especially  in  childhood 
when  alcohol,  as  a  cause  of  hepatic  cirrhosis,  can  be,  in  a  large  propor- 
tion of  cases,  safely  ignored,  that  we  feel  disposed  to  accept  the  view 
that  the  products  of  faulty  digestion  and  certain  stimulating  kinds  of 
food  conveyed  to  the  liver,  set  up  interstitial  hepatitis.  It  is  well  known 
that  many  of  the  lower  animals  (cow,  pig,  horse,  deer,  etc.)  are  subjects 
of  hepatic  cirrhosis.  The  fawns  at  Guy's  Hospital  to  which  the  students 
from  time  to  time  gave  linseed  meal  as  a  bonne  bouche,  died  of  cirrhosis 
of  the  liver. 

It  is  impossible  to  bring  much  evidence  in  favor  of  this  mode  of  cau- 
sation from  the  cases  that  we  are  analyzing,  owing  to  the  absence  of  in- 
formation as  to  the  habits,  diet,  etc.,  of  the  patients.  In  the  two  cases 
observed  by  myself,  the  children  habitually  partook  of  the  same  kind  of 
food  as  their  parents,  and  that  was  at  least  of  a  stimulating  character 
for  children,  the  family  being  noted  for  the  excellence  of  their  cuisine. 

Besides  food  containing  articles  more  or  less  irritating  to  the  liver, 
besides  new  products  from  faulty  digestion,  there  is  a  class  of  bodies 
which  were  hardly  known  when  Budd  wrote  his  article,  that  may  play 
a  part  in  the  production  of  interstitial  hepatitis — such  are  the  alkaloidal 
products  of  albuminous  decomposition  which  have  of  late  years  been 
receiving  attention — the  ptomaines.  Some  of  these  may  be  the  initiating 
cause  of  interstitial  hepatitis.  This  subject  lias  not  as  yet  received  much 
attention. 


360     HOWARD,   HEPATIC   CIRRHOSIS  IN  CHILDREN. 


The  age  at  which  cirrhosis  of  the 


at  birth 

"    3   month > 

«  17 

"  20 

"    2  years 
"    3  " 


5 

5| 

6 

7 


"  9 

a  10 

"  11 
u  12 

"  13 
"  14 

"  18 

Not  stated  . 


ver  occurred  in  these  children  was 

.  1 

.  1 

.  2 

.  1 

.  1 

.  2 

.  2  J 


under  3-^  years,  10 


5  to  8  inclusive,  13 


2 

•  1  J 

.  5 

.  7 

.  7 

.  5 

.  4 


9  to  13  inclusive,  28 


1  j-  14  to  18  inclusive,  3 

1  J 

2 


56 

According  to  this  analysis  the  greatest  liability  in  childhood  to  hepatic 
cirrhosis  is  from  the  ninth  to  the  12th  year  inclusive. 

As  regards  sex,  there  were  35  males,  17  females,  and  in  4  other  cases 
the  sex  was  not  stated.    (The  syphilitic  cases  are  not  included.) 

Referring  to  the  character  of  the  cirrhosis  in  these  56  non-syphilitic 
cases,  the  atrophic  form  obtained  in  19,  the  hypertrophic  in  13  ;  in  6  the 
organ  Avas  of  its  normal  size ;  in  16  this  point  is  not  mentioned,  and  in  2 
instances  the  patient  was  yet  living  when  reported  upon. 

The  symptoms  of  hepatic  cirrhosis  in  children  are  identically  those  of 
the  disease  in  the  adult.  I  shall  speak  very  briefly  upon  a  few  of  them. 
In  the  two  examples  seen  by  the  writer,  there  were  present  on  the  face 
stigmata  composed  of  collections  of  dilated  minute  venules.  Although 
they  have  been  spoken  of  by  some  few  authors,  they  are  rarely  alluded 
to  in  systematic  descriptions  of  cirrhosis,  and  are  mentioned  but  once  in 
the  records  of  the  otner  cases,  61  in  number,  which  I  have  collected 
and  studied.  Their  presence  should  suggest  an  examination  of  the 
liver  with  special  reference  to  the  probable  existence  of  cirrhosis. 

The  opinion  commonly  held  by  the  profession  is  that  cirrhosis  of  the 
liver  is  a  non-febrile  disease,  yet  in  10  out  of  52  cases,  uncomplicated  by 


HOWARD,  HEPATIC   CIRRHOSIS   IN   CHILDREN.  361 

other  affections  that  might  produce  pyrexia,  cirrhosis  was  associated  with 
fever;  that  is,  in  19.2  per  centum.  The  same  association  obtained  in 
5  other  instances  in  which  either  simple  or  tuberculous  inflammation 
complicated  the  cirrhosis  and  may  have  produced  the  pyrexia.  Dr.  R. 
E.  Carrington,1  who  has  recently  drawn  attention  to  this  circumstance, 
found  an  irregular  febrile  temperature  present  in  18  out  of  44  cases  of 
cirrhosis,  or  in  43  per  cent.  (This  list  includes  seven  children's  cases.) 
It  would  not,  however,  be  safe  to  conclude  from  these  figures  that  cir- 
rhosis is  less  frequently  associated  with  a  febrile  temperature  in  children 
than  in  adults ;  for  the  records  of  many  of  these  are  altogether  devoid  of 
details  on  this  point.  Of  these  10  febrile  cases  of  uncomplicated  cir- 
rhosis, 4  presented  the  hypertrophic  form,  4  the  atrophic,  and  2  had 
normal  sized  livers. 

In  the  56  cases  of  non-syphilitic  cirrhosis,  ascites  existed  in  34;  it  was 
absent  in  8,  and  it  was  not  mentioned  in  14.  It  is  interesting  to  note 
that  in  the  13  instances  of  hypertrophic  cirrhosis  ascites  was  absent  but 
twice,  not  mentioned  twice,  and  present,  contrary  to  the  opinions  of  some 
authors,  9  times.  On  the  other  hand,  abdominal  dropsy  was  absent  in 
4  out  of  19  instances  of  atrophic  cirrhosis,  in  which  it  is  thought  to  be 
rarely  wanting,  present  in  14,  and  not  mentioned  in  5  cases. 

Icterus,  more  or  less  deep,  was  present  in  23  cases,  absent  in  12,  and 
not  mentioned  in  21  of  the  non-syphilitic  group.  These  cases  do  not 
confirm  Fagge's  statement  that  where  cirrhosis  is  associated  with  jaun- 
dice the  liver  is  not  contracted,  as  a  rule,  but  is  increased  in  size.  For 
in  the  13  hypertrophic  examples  jaundice  was  present  7  times,  absent  3 
times,  and  not  mentioned  3  times;  while  in  the  19  atrophic  examples  it 
was  present  10  times,  absent  4  times,  and  not  mentioned  5  times.  In 
other  words,  icterus  coexisted  with  the  hypertrophic  form  in  70  per  cent., 
and  with  the  atrophic  in  71.4  per  cent. 

One  point  more  and  I  have  done.  The  fatal  issue  of  hepatic  cirrhosis 
in  children  is  brought  about  in  many  different  ways ;  but  there  are  three 
especially  frequent,  viz.,  by  toxaemia,  or  certain  disturbances  of  the 
nervous  system,  by  peritonitis,  and  by  asthenia,  in  the  production  of 
which  hemorrhage  plays  an  important  role.  These  three  modes  of  ter- 
mination obtained  respectively  in  12,  9,  and  8  instances.  Pneumonia 
seems  to  have  been  the  immediate  cause  in  3  instances.  The  following 
affections  held  the  same  relation  respectively  in  one  instance  :  pleuritis, 
pulmonary  congestion,  tuberculous  meningitis,  ulceration  of  the  entire 
colon,  and  "  diarrhoea,  with  fits." 

The  toxsemic  symptoms  in  these  children,  the  subjects  of  hepatic  cir- 
rhosis, have  been  more  especially  violent  fits  of  crying,  and  frequently 
of  screaming,  delirium,  dilated  pupils,  stupor,  tremor,  twitchings,  clonic 


1  Guy's  Hospital  Reports,  vol.  4i 


362     HOWARD,  HEPATIC   CIRRHOSIS   IN  CHILDREN. 


or  tetanic  convulsions,  rigidity,  coma  and  hemorrhages  from  stomach, 
nose,  intestines,  or  kidneys. 

In  conclusion,  it  results  from  this  analysis  of  these  63  cases  of  hepatic 
cirrhosis  in  children — 

1st.  That  most  of  the  established  causes  of  the  disease  in  adults  obtain 
also  in  children,  more  especially  the  use  of  alcohol,  present  in  15.8  per 
cent,  of  the  whole  number ;  syphilis,  chiefly  hereditary  syphilis,  present 
in  11  per  cent ;  tuberculous  disease  of  other  organs  than  the  liver,  in  11 
per  cent. ;  also,  but  much  less  frequently  than  these,  venous  congestion 
of  the  liver,  peritonitis,  and  a  general  tendency  to  connective  tissue 
formation  in  the  system. 

2d.  That  syphilis  occasionally  tends  to  a  diffuse  interstitial  hepatitis 
or  cirrhosis,  by  first  inducing  an  adhesive  inflammation  of  the  portal 
vein. 

3d.  That  a  general  arterio-capillary  fibrosis  is  not  proved  by  these 
cases  to  be  the  usual,  and  probably  not  even  a  frequent,  cause  of  hepatic 
cirrhosis  in  childhood. 

4th.  That  more  than  half  of  the  cases  of  hepatic  cirrhosis  in  children 
do  not  appear  to  be  produced  by  the  above-mentioned  well-established 
causes  of  that  affection. 

5th.  That  there  is  some  evidence  that  cirrhosis  of  the  liver  may  be 
very  exceptionally  induced  by  the  acute  infectious  diseases — cholera, 
typhoid  fever,  measles,  scarlatina,  but  that  proof  of  this  is  wanting. 

6th.  That  the  habitual  use  of  a  stimulating  diet,  or  the  absorption  of 
the  products  of  faulty  digestion,  are  probably  fruitful  sources  of  hepatic 
cirrhosis  in  children. 

7th.  That  it  is  in  harmony  with  what  is  known  of  the  causes  of  he- 
patic cirrhosis  to  believe  that  the  bodies  known  as  ptomaines  may  be 
capable  of  exciting  a  cirrhotic  condition,  and  that  investigation  of  this 
subject  deserves  attention. 

8th.  That  the  period  of  childhood  most  liable  to  cirrhosis  of  the  liver 
is  from  the  ninth  to  the  fifteenth  year  inclusive,  but  that  it  may  be  con- 
genital and  may  occur  at  any  age  after  birth. 

9th.  That  it  is  twice  as  frequent  in  male  children  as  in  female. 

10th.  That  its  symptoms  are  essentially  the  same  in  childhood  as 
adult  life. 

11th.  That  it  is  frequently  accompanied  by  pyrexia. 

12th.  That  ascites  or  icterus,  and  frequently  both  together,  are  of 
common  occurrence  in  the  atrophic  and  the  hypertrophic  forms. 

13th.  That  the  group  of  symptoms  which  have  been  referred  to  cho- 
lsemia  or  to  cholestersemia  or  to  acholia,  and  even  sometimes  to  uraemia, 
frequently  ushers  in  the  fatal  issue  of  hepatic  cirrhosis  in  children. 

Note. — The  author  regrets  not  having  had  the  opportunity  of  seeing 
a  valuable  article  on  "  Infantile  Cirrhosis,"  published  by  M.  le  Dr.  P. 


CLARKE,   ACTION    OF   SULPHATE    OF   SPARTEIN.  363 


Laure  et  M.  Honorat,  in  the  March  (1887)  number  of  the  Revue  Men- 
suelle  des  Maladies  de  VEnfance,  before  having  written  this  paper,  as  the 
French  communication  contains  some  original  cases,  as  well  as  others 
published  by  previous  writers,  the  works  of  some  of  whom  he  had  been 
unable  to  consult,  and  of  others  he  had  overlooked.  Dr.  E.  F.  Marsh's 
case,1  and  Dr.  Wesley  M.  Carpenter's  comments2  upon  it,  also  escaped 
the  author's  notice.  Dr.  Carpenter  has  specimens  of  cirrhosis  of  the 
liver  from  children  of  four  and  seven  years  of  age. 


ON  THE  THERAPEUTIC  ACTION  OF  THE 
SULPHATE  OF  SPARTEIN. 

By  J.  Mitchell  Clarke,  M.A.,  M.B.  Cantab., 

ASSISTANT  PHYSICIAN  TO  THE  BRISTOL  GENERAL  HOSPITAL;  ASSISTANT  LECTURER  ON  PHYSIOLOGY  AT 
THE  BRISTOL,  MEDICAL  SCHOOL. 

Fick  and  Raymond,  the  first  experimenters  on  the  action  of  spar- 
tein,  one  of  the  two  principles  contained  in  the  broom,  concluded  that  it 
acted  chiefly  on  the  nervous  system.  See,3  in  1883,  advocated  its  use  as 
a  therapeutic  agent  in  cardiac  diseases ;  stating  that  it  strengthened  the 
pulse  as  energetically  as  digitalis ;  that  it  was  the  best  known  regulator 
of  the  cardiac  rhythms ;  that  it  quickens  the  heart's  action  in  grave 
atonic  conditions;  that  its  effects  are  apparent  in  an  hour  or  so  after  its 
administration,  and  last  three  or  four  days  after  it  has  been  discon- 
tinued. 

Laborde4  and  Legris  confirmed  the  above  views,  stating  also  that 
spartein  quickened  a  slow,  but  retarded  an  unduly  fast  pulse,  and  that 
the  dose  was  from  one  and  a  half  to  three  and  three-quarters  grains 
daily.  These  observers  found  that  in  animals  the  heart's  beat  was 
strengthened  and  slowed,  and  the  quantity  of  urine  increased.  One 
and  a  half  grains  did  not  injure  a  dog  of  sixteen  to  eighteen  pounds 
weight,  but  a  dose  of  thrice  this  amount  caused  a  tetaniform  condition, 
with  death  from  respiratory  paralysis,  the  heart  continuing  to  beat 
regularly.  In  the  frog  the  heart  continued  to  beat  an  unusually  long 
time  after  death.  They  were  inclined  to  think  that  the  effect  on  the 
heart  is  produced  partly  by  stimulation  of  the  cardiac  muscle,  partly  by 
stimulation  of  nervous  centres. 

Dr.  Hans  Voight5  found  that  in  small  doses  sulphate  of  spartein 
increases  the  energy  of  the  cardiac  contractions,  and  raises  the  arterial 
tension,  with  a  corresponding  diuretic  action.    At  first  respiration  is 

i  Vide  The  Medical  Kecord,  N.  Y.,  Dec.  19,  1885,  p.  84.  -  Ibid.,  .lau.  16,  1886,  p.  »>•». 

3  Gaz.  Hebdom.,  Nov.  1885,  quoted  in  Med.  Chron.,  Sept.  1886. 

4  Compt.  RendusSoc.  de  Biol.,  1885,  ii.  €90,  quoted  in  Med  OhroQ.,  Sept  1886. 

5  Centralblatt  f.  d.  gesammt.  Therap.,  Oct.  1886. 


364    CLARKE,  ACTION   OF   SULPHATE   OF  SPARTEIN. 


increased,  but  afterward  somewhat  lessened  in  frequency.  There  is 
often  a  slight  narcotic  action.  Symptoms  of  intoxication,  such  as  dizzi- 
ness, headache,  palpitation,  and  nausea,  seldom  occur  after  small  doses 
(one-sixteenth  to  one-quarter  of  a  grain),  and  pass  off  during  the  con- 
tinued administration  of  the  drug. 

Gluzinski1  found  that  the  main  effect  of  spartein  consists,  in  a  slow- 
ing of  the  heart's  action,  and  in  raising  of  the  blood  pressure  more 
marked  in  cold-blooded  animals.  In  mammals  he  distinguishes  a  first 
and  third  period  of  action,  in  which  retardation  is  more  marked  than  in 
the  second  period,  when  acceleration  may  even  take  place,  and  explains 
these  phenomena  by  variations  in  the  irritability  of  the  pneumogastrics 
and  of  the  cardiac  muscle.  Reflexes  at  first  increased  are  subsequently 
lowered.  Death  occurs  from  asphyxia  depending  upon  a  lesion,  not 
only  of  the  medulla  oblongata,  but  also  of  the  respiratory  muscles.  He 
considers  spartein  inferior  to  digitalis  in  energy  of  action,  but  superior 
in  rapidity. 

The  following  observations  were  made  on  patients  at  the  same  time  of 
the  day  in  all  cases,  and  with  regard  to  meals  and  other  circumstances, 
as  far  as  possible,  under  the  same  conditions.  For  the  tracings  a  Dud- 
geon's sphygmograph,  that  had  been  selected  from  several,  and  had 
been  found  previously  to  give  accurate  tracings,  was  used ;  and  as  the 
personal  equation  is  no  unimportant  factor  in  sphygmographic  tracings, 
I  may,  perhaps,  say  that  I  had  had  an  extensive  experience  in  taking 
them  before.  For  the  quantity  of  the  urine,  since  these  observations 
were  made  on  out-patients,  I  had  to  depend  on  their  statements,  and 
therefore  the  most  intelligent  of  the  patients  were  selected  for  this 
purpose,  especially  in  those  cases  in  which  the  amount  of  urine  was 
estimated. 

The  most  important  actions  of  spartein  are  to  strengthen  the  cardiac 
beats,  to  raise  the  arterial  tension,  and  to  regulate  the  pulse,  and  its 
action  appears  to  differ  in  some  respects  according  to  the  dose  given. 
When  given  by  the  mouth  the  first  beneficial  effects  begin  to  be  apparent 
in  nearly  all  cases  about  thirty  minutes  after  it  has  been  swallowed,  in 
some  not  till  forty-five  minutes  after.  The  effect  of  individual  doses  (one- 
sixteenth  to  one-quarter  of  a  grain)  lasts  for  about  four  or  five  hours, 
of  larger  doses  (one  to  two  grains)  somewhat  longer,  and  gradually  pass 
off.  When  it  has  been  taken  regularly  for  some  days  or  weeks  the  effect 
lasts  from  three  to  four  days,  or  even  six  days  after  its  administration 
has  been  discontinued  in  cases  that  are  not  permanently  relieved.  In  a 
few  of  the  cases  given  below,  the  effect,  from  reasons  I  could  not  discover, 
was  not  so  protracted,  passing  off  with  the  discontinuance  of  this  remedy. 
The  doses  employed  varied  from  one-sixteenth  of  a  grain  every  four  hours 

1  Fezegad  de  karski,  No.  1,  1887,  and  Vratch,  No.  3,  1887. 


CLAEKE,   ACTION    OF   SULPHATE   OF   SPABTEIN  365 


to  twelve  grains  in  the  twenty-four  hours,  no  toxic  effects  of  even  the 
slightest  severity  were  produced,  and  there  was  no  evidence  of  accumu- 
tion  in  cases  where  the  remedy  was  taken  for  from  three  to  four  months 
continuously. 

The  first  effect,  coming  on  about  thirty  minutes  after  exhibition  of  the 
dose,  consists  in  a  strengthening  of  the  force  of  the  heart-beats,  with  a 
slowing  and  regulation  of  the  pulse  in  cases  where  this  is  abnormally 
rapid.  Closely  following  on  this,  at  about  forty-five  minutes  or  one 
hour  after  the  dose,  the  arterial  tension  is  raised,  and  shortly  before  this 
rise  of  tension,  or  at  the  same  time,  the  surface  of  the  skin  becomes  red, 
flushed,  and  moist,  with,  in  some  instances,  free  perspiration.  During 
the  next  two  or  three  hours,  for  the  first  part  of  the  time,  the  surface  of 
the  body  remains  flushed  and  warm,  the  arterial  tension  continues  to 
rise,  or  to  remain  at  a  higher  level  than  before  the  dose,  and  the  rate  of 
the  pulse  to  be  slowed  until  it  reaches  or  approaches  the  normal,  while 
from  the  first  the  heart  beats  with  increased  force ;  the  jDatient,  mean- 
while experiences  a  marked  sense  of  well-being  and  of  comfortable 
warmth,  with,  if  it  existed,  loss  of  precordial  distress,  irregular  cardiac 
action,  and  dyspnoea.  Xow  it  seems  to  me  that  this  rise  of  arterial 
pressure,  with  increased  amount  of  blood  sent  through  the  skin  (and 
kidneys),  can  only  be  explained  in  one  way,  by  a  special  action  of  spar- 
tein  on  the  medullar  vasomotor  centre,  this  centre  by  causing  contrac- 
tion of  the  vessels  of  the  splanchnic  area,  and  so  diminishing  the  amount 
of  blood  sent  through  the  great  splanchnic  vessels  raises  the  blood- 
pressure,  and,  at  the  same  time,  an  increased  amount  of  blood  is  driven 
through  the  vessels  of  the  skin  and  kidneys.  This  increased  cutaneous 
blood-supply  will  be  sufficient  to  explain  the  moistening  of  the  skin  that 
takes  place,  but  where  free  sweating  occurs,  I  think,  we  must  also  sup- 
pose a  stimulation  of  the  secreting  cells  of  the  sweat-glands  by  the  drug. 

Spartein  also  causes  a  variable  increase  in  the  amount  of  the  urinary 
secretions,  with  increased  excretion  of  urea,  in  correspondence  with  the 
increase  of  water,  and  this  diuretic  action  we  should  anticipate  as  a 
consequence  of  the  strengthened  vis  a  tergo,  the  rise  of  blood-pressure, 
and  the  increased  quantity  of  blood  passing  through  the  kidneys.  This 
flushing  of  the  surface  was  a  constant  result,  except  in  a  few  cases. 
On  respiration  spartein  produces  an  initial  quickening,  followed  by  a 
slowing,  reaching  or  approaching  to  the  normal  rate,  at  the  same  time 
the  respiratory  movements  are  of  greater  depth. 

Now  some  minor  modifications  of  the  above  statements  require  notice. 
First,  as  in  Gluzinski's  observations,  quoted  above,  in  some  cases  the 
division  of  the  action  of  spartein  into  three  periods,  an  intial,  and  later 
one,  of  slowing  of  the  pulse  and  respiration,  with  an  intermediate  period 
of  quickening,  was  noticed ;  this  effect  occurred  about  seventy-five  to 


366    CLARKE,   ACTION    OF   SULPHATE    OF  SPAETEIN. 

ninety  minutes  after  the  dose  was  taken,  and  in  only  two  or  three 
patients ;  it  was  especially  marked  in  a  case  of  aortic  regurgitation. 

Secondly,  the  best  results,  in  all  respects,  were  obtained  when  the 
dose  was  given  often ;  every  four  hours  appeared  the  most  satisfactory 
arrangement.  Then  small  and  large  doses  have  a  somewhat  different 
effect,  and  this  explains  some  of  the  discrepancies  in  the  statements  of 
the  observers  above  quoted.  Small  doses,  one-sixteenth  to  one-twelfth 
of  a  grain,  produce  the  maximum  effect  in  the  regulation  of  the  pulse. 
In  one  instance  doses  of  one-tenth  of  a  grain  rendered  a  previously 
arhythmic  pulse  quite  regular  when  large  doses  had  failed  to  do  so,  and 
I  had  frequent  occasion  to  note  the  same  result.  These  small  doses 
were  also  best  for  relieving  palpitation,  and  for  quieting  down  violent 
cardiac  pulsation;  small  amounts  also  appeared  to  strengthen  the  force 
of  the  heart-beats,  with  very  little  raising  of  the  arterial  tension,  and 
the  stimulating  cardiac  action,  combined  with  small  increase  of  tension, 
will  be  doubtless  of  great  service  where  it  is  important  to  strengthen 
the  force  of  the  heart-beats  without  increasing  markedly  the  peripheral 
resistance.  Larger  doses,  one  to  two  grains,  powerfully  increase  the 
force  of  the  beats,  but,  at  the  same  time,  even  more  powerfully  raise  the 
arterial  tension,  and  as  an  effect  of  this  I  found,  in  many  cases,  violent 
pulsation  produced,  with  precordial  pain,  and  a  strong  but  very  tense 
pulse. 

When  the  drug  is  taken  regularly  for  some  time,  the  general  effect, 
apart  from  that  of  each  individual  dose,  is  found  often  to  be  an  acceler- 
ation of  the  pulse  and  respiration-rate,  giving  way,  after  the  first  day 
or  days,  to  a  subsequent  slowing. 

As  to  accumulation,  an  overdose,  taken  for  some  time,  appears  to 
produce  very  high  tension  of  the  pulse,  and,  as  in  the  case  of  mitral 
stenosis,  "  tightness  of  the  chest,"  with  sharp  cutting  pains  and  throbbing 
over  the  heart ;  in  another  case,  after  spartein  had  been  taken  for  two 
months  continuously,  the  previously  rapid  pulse  was  slowed  to  fifty 
beats  in  the  minute ;  but  this  was  in  an  elderly  man,  and  accompanied 
by  a  sense  of  increased  strength  and  well-being,  with  relief  of  dyspnoea, 
etc.  These  were  the  only  two  cases  in  which  I  could  at  all  obtain  any 
evidence,  although  I  was  constantly  on  the  lookout  for  it,  of  toxic 
effects. 

As  to  the  other  evidences  of  intoxication  mentioned  above,  nausea 
occurred  in  a  few  cases,  but  soon  passed  off ;  palpitation  and  precordial 
pain  certainly  result  from  too  large  a  dose,  due  probably  to  the  beat 
laboring  against  an  excessive  peripheral  resistance,  but  these  symptoms 
are  not  produced  by  smaller  doses. 

Cough  was  generally  relieved,  owing  probably  to  increased  depth  and 
regularity  of  respiratory  movements ;  dyspeptic  pains  also  often  diap- 
peared.  This  I  attributed  to  the  improvement  of  the  circulation. 


CLARKE,  ACTION   OF   SULPHATE   OF   SP  ARTE  IN .  367 

It  remains  to  be  said  that  in  cases  where  the  left  ventricle  is  much 
hypertrophied,  or  when,  from  any  cause,  the  heart  is  beating  too  vio- 
lently, spartein  quiets  and  diminishes  the  force  of  its  action  ;  also  that 
in  some  instances  of  abnormally  slow  pulse,  spartein  quickens  the  rate 
until  it  reaches  or  approaches  the  normal,  and  finally,  that  when  the 
arterial  tension  is  already  very  high,  its  action  is  spent  in  strength- 
ening the  heart-beats. 

The  foregoing  seems  to  lead  to  the  conclusion  that  spartein  belongs  to 
the  digitalis  group,  and  acts  directly  on  the  cardiac  muscle  and  the  cardio- 
inhibitory  centre  in  the  medulla,  thus  giving  rise  to  increased  force  of 
cardiac  contractions,  and  through  the  pneumogastrics  to  regulation  of 
the  pulse,  generally  in  the  direction  of  slowing ;  in  cases,  however,  in 
which  the  pulse  is  abnormally  slow,  the  drug  often  accelerates  it.  A 
general  rise  of  arterial  tension  takes  place,  partly  as  the  effect  of  the 
increased  force  of  the  heart-beats,  but  probably  chiefly  due  to  a  stimu- 
lation of  the  medullary  vasomotor  centre  causing  contraction  of  the 
vessels  of  the  splanchnic  area,  with  therefore  an  increased  blood  supply 
to  the  skin  and  kidneys.  This  seems  to  me  the  only  way  in  which  to 
explain  a  general  rise  of  blood-pressure,  with,  at  the  same  time,  a  vastly 
increased  quantity  of  blood  driven  through  the  cutaneous  vessels.  The 
correlation  of  skin  and  kidneys  in  normal  function  lends  itself  to  the 
supposition  that  at  the  same  time  more  blood  is  passing  through  the 
renal  vessels,  thus  causing  increased  excretion  of  urine.  The  more 
marked  diuresis  produced  by  larger  doses  may  be  due  to  stimulation  of 
the  renal  cells,  as  in  the  case  of  digitalis,  according  to  many  observers. 
The  quantity  of  urine  is  not,  however,  invariably  increased,  perhaps  in 
relation  with  the  free  diaphoresis  produced  by  spartein  in  some  patients. 
No  effect  on  the  temperature  was  noted.  Tracings  from  three  cases  are 
here  given. 

The  following  tracings1  were  taken  at  short  intervals  of  time  after 
spartein  had  been  administered. 

Case  I. — A  bad  case  of  mitral  regurgitation  in  a  youth  of  nineteen. 
The  chest  was  bulged  out  over  the  precordial  area,  and  the  area  of  cardiac 
dulness  was  bounded  above  by  the  third  rib,  on  the  right  by  the  right 


border  of  the  sternum,  and  expended  beyond  the  nipple.  The  apes 
beat  was  one  inch  outside  the  nipple  in  the  fifth  space. 


Tracing  1. 


Tracing  2. 


1  Pressure  three  and  a  quarter  ounces  in  all  tracings. 


368     CLARKE,  ACTION   OF   SULPHATE   OF  SPARTEIN . 

Tracing  No.  1.  Pulse  120,  almost  hyperdicrotic ;  respiration  24;  face 
and  lips  very  livid.  Spartein  sulph.  one-quarter  grain  administered  at 
12.45  p.  m. 

At  1  p.  M.  there  was  no  change  in  character  of  pulse  tracings.  Pulse 
120  ;  respiration  24. 

Tracing  No.  2.  1.30  p.  m.  Pulse  90  ;  respiration  24 ;  much  less  lividity 
of  lips  ;  slight  rise  of  tension. 

Tracing  No.  3.  2  p.  m.  Pulse  84;  respiration  22  ;  blueness  of  lips  had 
disappeared  ;  the  skin  everywhere  was  now  warm  and  moist,  instead  of 
cold  as  before.   A  tracing  at  2.30  p.  m.  showed  a  further  rise  in  tension. 

Tracing  3.  Tracing  4. 

VviJU  IkkLk 


Tracing  No.  4.  3.15  p.  m.  Pulse  84  ;  respiration  20  ;  no  lividity ;  sur- 
face of  body  still  warm. 

The  improvement  in  appearance  was  now  striking  from  flushing  of 
the  surface.  He  improved  somewhat  for  three  or  four  weeks,  but  then 
made  no  further  advance  ;  the  rapidity  and  violence  of  the  cardiac  beats, 
shortness  of  breath,  etc.,  increased.  The  dose  of  spartein  was  raised 
gradually  from  one-twelfth  to  one-fourth  of  a  grain,  every  four  hours, 
without  effect.  He  died  after  being  in  bed  for  one  month.  Digitalis 
and  other  remedies  were  tried  without  any  benefit. 

The  following  tracings  are  from  a  case  of  mitral  stenosis. 

Tracing  No.  5  was  taken  before  administration  of  spartein.  Pulse  72 ; 
respiration  18. 


Tracing  5 


Tracing  No.  6  was  taken  after  spartein,  one-sixteenth  of  a  grain,  had 
been  given  every  four  hours  for  four  days. 

The  next  two  tracings  are  from  a  case  of  Graves's  disease. 


Tracing 


Tracing  8. 


Tracing  No.  7  was  taken  before  the  administration  of  spartein.  Pulse- 
rate  was  132  ;  respiration  36. 

Tracing  No.  8  was  taken  after  sulphate  of  spartein,  one-half  grain,  had 
been  taken  three  times  a  day  for  five  weeks.    Pulse  76  ;  respiration  18. 


CLARKE,   ACTION  OF   SULPHATE   OF   SPARTEIN.  369 


Of  ten  cases  of  mitral  regurgitation,  due  in  seven  to  rheumatic  fever, 
in  one  to  endocarditis  following  chorea,  in  the  other  two  patients  to 
anaemias  associated  with  violent  palpitation,  eight  were  completely  re- 
lieved, and  in  the  twTo  anaemic  patients  the  murmur  disappeared,  so  that 
it  was  probably  due  to  relative  incompetence  from  dilatation  of  the  left 
ventricle.  The  two  cases  that  did  not  improve  were  very  bad  ones,  and 
were  afterward  treated  by  digitalis,  and  other  measures,  without  any 
benefit.  The  quantity  of  urine  and  of  urea  excreted  was  increased  in 
six  patients.  Dyspnoea  and  precordial  pain  appeared  to  be  relieved 
first,  followed  by  the  disappearance  of  oedema  in  the  most  speedy  in- 
stance after  three  days'  treatment.  An  increased  feeling  of  well-being 
was  noticed  by  all,  at  first  even  by  the  two  patients  in  wrhom  the  car- 
diac symptoms  were  not  ameliorated.  The  pulse  was  rendered  less 
frequent,  stronger,  and  more  regular. 

In  two  or  three  instances  it  was  found  that  a  small  dose,  one-sixteenth 
of  a  grain,  given  at  intervals  of  three  or  four  hours,  produced  the 
greatest  regulating  effect  on  the  pulse,  and  relieved  arhythmia  where 
larger  and  less  frequent  doses  had  previously  failed  to  do  so.  A  study 
of  these  cases  and  of  others  shows  that  spartein  is  likely  to  be  of  great 
service  in  mitral  regurgitation,  relieving  the  symptoms  in  most  instances 
rapidly  and  completely. 

In  mitral  stenosis  we  may  expect  good  results  when  the  pulse  is  small, 
weak,  and  irregular,  but  in  this  form  of  heart  disease  the  effect  produced 
by  it  seems  of  shorter  duration,  and  more  immediately  dependent  on 
the  continual  administration  of  the  drug.  Though  the  patients  im- 
proved whilst  taking  it,  the  good  effects  ceased  on  leaving  it  off.  Four 
out  of  five  cases  of  mitral  stenosis  to  whom  I  gave  it  improved,  how- 
ever; one  being  able  to  lie  down  at  night,  which  had  been  impossible 
for  three  years  before. 

In  one  woman,  after  taking  one  grain  every  six  hours  for  three  weeks, 
sharp  cutting  pains  at  the  left  shoulder-blade  and  over  the  heart  came 
on,  with  a  feeling  of  tightness  in  the  chest.  These  symptoms  ceased  on 
reducing  the  dose. 

In  aortic  regurgitation,  when  the  violent  pulsation  of  a  greatly 
enlarged  heart  produces  much  pain  and  distress,  spartein  is  a  valuable 
remedy,  quieting  and  regulating  the  excited  cardiac  action  without 
unduly  prolonging  the  systole ;  in  these  cases  tracings  showed  that  the 
excessive  force  and  rapidity  of  the  heart-beats  were  lessened,  pari  passu, 
with  a  gradual  fall  in  the  arterial  tension.  Small  doses  were  here  most 
beneficial.  In  other  forms  of  hypertrophy  it  will  be  found  useful  when 
the  heart  acts  violently  and  irregularly.  In  the  hypertrophy  combined 
with  extremely  high  tension  of  chronic  Bright's  disease  the  effect  was 
to  stimulate  the  cardiac  contractions,  while  the  arterial  tension  was  not 
further  raised  nor  the  quantity  of  urine  increased. 

NO.  CLXXXVIII.— OCTOBER,  1887.  '24 


370    CLARKE,  ACTION   OF   SULPHATE   OF  SPARTEIX. 


In  a  number  of  patients  suffering  from  various  forms  of  chronic  lung 
disease  with  obstruction  to  the  pulmonary  circulation,  and  where  com- 
pensatory changes  had  not  been  established  in  the  right  heart,  or  after 
being  established  had  broken  down,  I  found  spartein  of  great  value  ; 
dyspnoea,  precordial  pain,  and  palpitation  were  relieved  almost  at  once, 
and  in  several  a  cough  grew  less.  In  two  cases,  where  there  was  reason 
to  suspect  fatty  or  other  changes  of  malnutrition  in  the  heart-muscle, 
no  benefit  was  noted. 

Of  five  cases  of  asthma,  four  were  entirely  relieved,  the  other  was  not 
benefited.  The  administration  of  spartein  was  combined  with  inhalations 
of  pyridin  ;  improvement  was  slow,  all  being  under  treatment  from  one 
to  five  months.  The  severity  of  the  symptoms  was  very  much  dimin- 
ished, the  attacks  cut  short,  and  rendered  less  frequent  after  a  short 
time,  one  to  two  weeks,  and  the  patients  could  keep  comfortable  whilst 
they  continued  the  drug,  but  if  they  left  it  off  were  liable  to  relapse. 
Gradually  the  attacks  returned  less  and  less  often  and  became  milder, 
and  finally  ceased  at  the  end  of  the  winter ;  so  that  the  ultimate  effect 
in  four  out  of  five  cases  was  satisfactory,  though  the  slow  progress  w7as 
disappointing  after  the  enthusiastic  statements  that  have  been  made  as 
to  the  value  of  spartein  in  asthma.  In  one  old  man  suffering  from 
asthma  and  chronic  bronchitis  the  pulse-rate,  that  had  previously  been 
96-84,  was  slowed  to  50  in  the  minute,  and  was  rendered  more  forcible. 
This  slowing  took  place  after  two  months'  continuous  administration  of 
the  drug,  and  though  accompanied  by  marked  amelioration  of  general 
symptoms,  must  be,  perhaps,  regarded  as  due  to  accumulation. 

In  cases  of  palpitation,  without  evidence  of  organic  heart  disease, 
spartein  gives  immediate  relief,  which  becomes  permanent  after  the. 
remedy  has  been  continued  for  a  week  or  two.  In  chlorosis,  with  dila- 
tation of  the  heart  and  the  usual  murmurs,  I  found  that  spartein,  given 
in  combination  with  iron,  quickly  relieved  palpitation,  pain,  dyspnoea, 
and  oedema  of  the  ankles,  and  in  due  course  the  murmurs  and  the 
evidences  of  dilatation  w7hen  present  disappeared. 

The  effects  of  spartein  in  three  cases  of  Graves's  disease  were  remark- 
able, and  if  a  wider  experience  cenfirms  them,  it  will  be  a  valuable 
remedy  in  this  disease.  In  two  of  the  cases  the  usual  remedies,  including 
a  long  course  of  arsenic,  and  the  passing  of  a  constant  current  through 
the  neck,  etc.,  had  been  tried  without  effect.  On  giving  spartein  the 
pulse-rate  dropped  in  one  week  from  constant  rates  of  132  and  136  to 
the  minute,  to  rates  of  72  and  84  respectively,  the  coincident  throbbing 
and  pulsation  of  the  thyroid  and  of  the  great  vessels  of  the  neck  ceased. 
Other  symptoms  were  relieved,  especially  the  nervousness  and  weakness 
previously  complained  of,  and  the  size  of  the  thyroid  tumor  distinctly 
diminished.  The  gain  in  strength  and  general  well-being,  with  improve- 
ment of  appearance  due  to  gain  of  flesh  and  color,  was  striking. 


OSLEE,  THE   CARDIAC   RELATIONS   OF   CHOREA.  371 


In  the  third  case,  a  more  severe  example  of  the  disease  than  either  of 
the  preceding,  there  was  general  improvement,  with  diminution  of  violent 
pulsation  in  the  thyroid  and  over  the  neck  and  face,  but  the  pulse-rate 
of  144  was  not  reduced  to  less  than  96  to  the  minute,  varying  between 
this  and  108.  This  patient  suffered  from  continual  fine  tremor  of  the 
muscles,  especially  in  the  limbs  ;  while  taking  spartein  this  tremor 
remained  absent,  but  returned  if  the  drug  was  left  off.  She  has  im- 
proved in  strength  and  feels  well  whilst  she  is  taking  it.  She  has  now 
been  taking  one-quarter  of  a  grain  ever  four  hours  for  six  months. 

I  gave  spartein  for  periods  varying  from  two  weeks  to  six  months  in 
daily  quantities  of  one-third  of  a  grain  to  twelve  grains,  the  latter  large 
dose  was  continued  in  one  case  for  a  month  with  benefit.  It  is  best  to 
begin  with  one-sixteenth  of  a  grain  every  four  hours,  and  gradually 
increase  up  to  two  grains,  if  necessary  until  the  desired  effect  on  the 
circulation  is  obtained.  When  the  dose  is  given  less  frequently  the 
result  does  not  seem  so  good  ;  sometimes  a  large  dose  may  be  gradually 
reduced  without  loss  of  effect.  There  is  no  fear  of  accumulation.  The 
signs  of  an  overdose  are  palpitation,  precordial  pain,  small,  rapid  pulse 
of  high  tension,  and  a  feeling  of  great  weakness,  or  even  trembling. 

Spartein  begins  to  act  in  about  thirty  minutes  after  it  has  been  taken 
by  the  mouth,  and  its  action  lasts  from  about  five  to  six  hours.  This 
rapidity  of  action,  at  first  consisting  in  a  stimulation  of  the  heart,  rise  of 
arterial  tension  not  occurring  until  a  little  later,  indicates  the  use  of 
spartein  in  asystolic  conditions  of  valvular  disease,  where  a  speedy 
effect  is  desired,  giving  it  superiority  over  more  slowly  acting  drugs. 

In  these  conditions,  too,  a  small  dose  should  be  employed  (one-six- 
teenth to  one-quarter  of  a  grain),  since  in  these  doses  spartein  seems 
powerfully  to  stimulate  and  regulate  the  heart  with  the  smallest  rise  of 
arterial  tension,  perhaps  not  more  than  is  the  normal  accompaniment 
of  increased  cardiac  force. 

Diuretic  effect  is  most  marked  with  fairly  large  doses,  half  a  grain  to 
two  grains ;  with  small  it  is  not  so  evident,  but  is  often  present. 
Flushing  of  the  surface  of  the  body  occurred  in  from  one  to  two  hours 
after  administration  in  most  cases. 


THE  CARDIAC  RELATIONS  OF  CHOREA. 
By  William  <  >sler,  M.H., 

PROFESSOR  OF  CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  ;  PHYSICIAN  TO  THE 
UNIVERSITY  HOSPITAL,  TO  THE  PHILADELPHIA  HOSPITAL.  AND  TO  THE 
INFIRMARY  FOR  NERVOUS  DISEASES. 

The  heart  symptoms  of  chorea  demand  special  consideration  as  among 
the  most  important  and  peculiar  features  of  the  disease.  Chorea  is  rarely 
a  fatal  disease  in  children,  and  hundreds  of  cases  may  be  treated  without 


372    OSLER,  THE   CARDIAC   RELATIONS   OF  CHOREA. 

a  death.  By  far  the  most  serious  fact  in  the  clinical  history  of  the  dis- 
ease is  the  occurrence  of  endocarditis ;  but  here  the  danger  is  remote, 
not  immediate,  and  lies  in  the  changes  which  an  acute  valvulitis  may 
initiate. 

A  satisfactory  study  of  the  cardiac  relations  of  chorea  must  embrace 
the  condition  during  the  attack,  and  the  subsequent  heart  history  after 
a  period  of  years.  The  first  question  has  engaged  the  attention  of  many 
workers,  and  an  attempt  is  here  made  to  work  out  the  second  on  a  scale 
not  hitherto  attempted. 

I.  Condition  of  the  Heart  during  the  Attack. 

Oftentimes  the  extreme  jactitation  renders  the  examination  of  a  choreic 
child  difficult  or  even  impossible.  I  make  it  a  rule  to  examine  the  bare 
chest.  Auscultation  through  the  clothing  is  not  trustworthy,  as  soft 
murmurs,  readily  audible  with  the  stethoscope,  may  easily  escape  detec- 
tion. It  is  a  good  plan  to  let  the  child  lie  quietly  on  a  lounge  for  some 
time,  and  make  the  first  examination  in  the  recumbent  position  when 
the  heart's  action  is  less  rapid.  Subsequently  the  effect  of  exercise  and 
of  the  erect  posture  may  be  tested. 

In  chorea,  as  in  rheumatism,  the  evidences  of  cardiac  disease  must  be 
sought  for,  as  it  is  rare  to  hear  complaints  of  either  palpitation,  pain,  or 
other  symptoms  which  would  direct  attention  to  the  heart. 

The  cardiac  disturbance  is  indicated  by  the  presence  of  murmurs, 
alteration  in  the  rate  or  rhythm  of  the  heart's  action,  and  by  pain. 

A  murmur  at  one  or  other  of  the  cardiac  areas  is  by  far  the  most 
common  sign  and  is  present  in  a  considerable  number  of  all  cases.  Of 
410  cases  in  the  records  of  the  Infirmary  for  Nervous  Diseases,  there 
were  120  which  presented  a  heart  murmur  at  the  time  of  examination. 
In  at  least  40  cases  there  was  either  no  note  or  an  imperfect  one,  and  in 
very  many  the  exigencies  of  out-patient  work  prevented  a  very  thorough 
examination.  It  can  safely  be  said  that  in  over  one- third  of  the  cases 
a  heart  murmur  was  detected,  and  I  have  no  doubt  that  this  number 
would  have  been  much  increased  had  each  child  been  stripped  and 
special  attention  given  to  the  auscultation  of  the  heart. 

Of  the  120  eases,  113  presented  the  apex  systolic  or  mitral  murmur, 
in  7  a  basic,  and  in  3  both  apex  and  basic.  In  15  cases  the  heart's 
action  was  noted  as  rapid,  and  in  6  as  irregular.  Pain  was  not  a  fre- 
quent complaint  and  was  noted  in  only  6  or  7  cases. 

It  is  common  experience  that  the  special  indication  of  heart  trouble 
in  chorea  is  the  presence  of  a  soft  systolic  bruit,  heard  best  at  the  apex 
or  over  the  body  of  the  ventricles  and  not  often  propagated  to  or  beyond 
the  mid-axilla.  Basic  systolic  murmurs  are  usually  associated  with 
anaemia  or  debility.  Diastolic  and  presystole  murmurs  rarely,  if  ever, 
occur  in  acute  chorea. 


OSLER,  THE   CARDIAC   RELATIONS   OF  CHOREA.  373 


Before  discussing  the  probable  nature  of  these  murmurs  it  will  be  well 
to  study  the  anatomical  condition  of  the  heart  in  fatal  cases.  Fortu- 
nately these  are  rare.    I  have  inspected  three  cases. 

Case  I. — S.,  a  girl,  aged  eleven;  had  had  acute  rheumatism.  Ad- 
mitted to  the  Montreal  General  Hospital,  under  Dr.  George  Ross,  with 
acute  chorea,  and  died  of  an  intercurrent  pneumonia.  The  movements 
had  almost  ceased  under  hypodermics  of  arsenic.  The  autopsy  (No. 
465  post-mortem  records  Montreal  General  Hospital)  showed  slight 
hypertrophy  of  the  heart,  somewhat  thickened  mitral  curtains  wTith 
numerous  irregular  warty  vegetations  just  inside  the  auricular  margins. 
Two  of  the  aortic  segments  also  presented  bead-like  vegetations  below 
the  corpora  Arantii. 

Case  II. — T.  B.,  a  boy,  aged  eleven,  had  chorea  in  May,  1880,  and  a 
second  severe  attack  in  July  of  the  same  year.  No  rheumatism.  No 
heart  murmur.  About  the  20th  of  February,  1881,  there  was  a  recur- 
rence, and  on  March  3d  he  again  came  to  the  general  hospital  to  see 
Dr.  Molson.  About  the  10th  he  began  to  get  feverish  and  extremely 
restless.  On  the  14th  the  temperature  rose  above  104°  F.,  and  he  be- 
came comatose.  The  left  arm  seemed  powerless,  the  right  arm  and  leg 
were  constantly  twitching.  On  the  15th  the  temperature  reached  105° 
F.,  and  there  were  cutaneous  ecchymoses.  He  died  on  the  morning  of 
the  16th.  The  autopsy  showed  very  extensive  mitral  valvulitis,  the 
vegetations  large,  soft,  grayish-white  in  color.  No  chronic  affection  of 
the  valves.  The  spleen  and  kidneys  contained  many  recent  infarcts. 
The  brain  and  membranes  healthy,  with  the  exception  of  a  spot  of 
grayish-red  softening  in  the  right  corpus  striatum  (lenticular  nucleus) 
about  the  size  of  a  cherry.  It  was  no  doubt  embolic,  though  the  arteries 
of  the  perforated  space  were  carefully  examined  for  emboli  without 
success. 

Case  III. — Emma  M.,  aged  eighteen,  admitted  to  the  Montreal  Gen- 
eral Hospital,  under  Dr.  George  Ross,1  and  died  in  five  days  of  exhaus- 
tion. There  was  no  rheumatism,  and  the  attack  had  followed  a  fright  five 
days  before  admission.  Here,  too,  the  only  important  lesion  was  on  the 
mitral  valves — a  row  of  soft  warty  vegetations  on  the  auricular  face  just 
within  the  free  margins. 

The  statistics  of  fatal  cases  of  chorea  have  been  collected  by  Sturges2 
and  Raymond.3  Of  eighty  cases,  representing  the  combined  experience 
of  Guy's,  Bartholomew's,  St.  George's,  and  St.  Thomas's  Hospitals, 
Sturges  states  that  there  were  only  five  with  the  heart  valves  and  peri- 
cardium reported  healthy. 

Excluding  the  London  cases  from  Raymond's  table  of  79  cases,  there 
are  left  34,  in  only  19  of  which  there  were  specific  statements  as  to  the 
condition  of  the  heart,  and  in  every  one  of  these  endocarditis  was  present. 
I  have  found  the  reports  of  15  additional  cases,4  which,  with  the  three 

1  Canada  Medical  and  Surgical  Journal,  vol.  xi.  -  Chorea.    London,  1881. 

3  Dictionuaire  encyclopedique  des  Sciences  Medicates. 

4  Mackenzie  (Trans.  Inter.  Med.  Congress,  1881),  six  cases,  live  of  endocarditis.  Donkin  and  Hebb,  1 
case,  valves  normal  (Med.  Times  and  Gaz  ,  1884,  ii  ).  Baxter  (Brain,  vol.  ii  )  one  case.  Morell-Luvelloe 
(Revue  des  Maladies  de  l'Enfance,  1884),  one  case.  Frank  ( Allg.  Wiener  mod.  Zeitung,  187i»),  one  MM. 
Maixner  (Med.-Chir.  Centralblatt,  Wien,  1882),  one  case.  Koch  (Deutsches  Archiv  f.  klin.  Med.,  Bd. 
xl.),  four  cases 


374    OSLER,  THE  CARDIAC   RELATIONS   OF  CHOREA. 

here  given  makes  18,  in  16  of  which  there  was  mitral  endocarditis.  We 
may  say  that  of  115  fatal  cases  of  chorea,  with  notes  of  the  state  of  the 
heart,  in  not  more  than  10  was  this  organ  found  normal,  and  in  the 
great  proportion  of  the  cases  the  lesion  was  acute  mitral  valvulitis. 

One  other  point  must  be  considered  before  we  speak  of  the  nature  of 
the  heart  murmur. .  In  what  proportion  of  the  cases  is  there  a  history 
of  rheumatism?  In  35  of  the  120  cases,  29.1  per  cent.,  there  was  a  note 
of  articular  affection,  either  acute  or  subacute,  or  of  pains  which  might 
be  regarded  as  rheumatic. 

Much  has  been  written  in  explanation  of  the  heart  murmur  of  chorea ; 
an  idea  of  how  much  may  be  gathered  from  the  fact  that  a  discussion  of 
the  theories  which  have  been  advanced  occupies  twelve  pages  in  Hayden's 
work  on  Diseases  of  the  Heart.  We  are  concerned  chiefly  with  the  apex 
systolic  murmur,  universally  recognized  as  the  most  frequent  and  char- 
acteristic sign  of  implication  of  the  heart  in  chorea.  Speaking  generally, 
^Ye  meet  with  such  a  murmur  in  mitral  endocarditis,  or  in  relaxation  of 
the  ventricular  walls,  such  as  occurs  in  anaemia  and  fevers,  and  it  is 
attributed  to  regurgitation  through  the  mitral  orifice,  owing  either  to 
absolute  insufficiency,  in  consequence  of  the  endocarditis,  or  to  relative 
insufficiency  when  the  normal  valves  are  unable  to  close  an  orifice  en- 
larged as  a  result  of  relaxation  of  the  heart  muscle.  In  chorea  a  special 
theory  of  musculo-papillary  spasm  has  been  advanced  to  account  for  the 
mitral  murmur. 

It  would  be  fruitless  to  re-discuss,  in  all  its  aspects,  a  subject  so  well 
and  ably  presented  in  various  works,  particularly  in  those  of  Hayden 
and  Sturges.  That  there  is  such  a  condition  as  spasm  of  the  papillary 
muscles  resulting  in  a  "want  of  correspondence  between  the  fibres  of  the 
ventricle,  which  obliterate  the  cavity  and  those  which  close  the  valve," 
is  a  plausible  hypothesis  unsupported,  so  far  as  I  know,  by  any  clinical  or 
anatomical  facts,  while  the  general  immunity  of  involuntary  muscular 
organs  in  chorea  speaks  strongly  against  it. 

Sturges  thinks  that  there  may  be  a  fatigue  paresis  of  the  papillary 
muscles,  similar  to  that  which  sometimes  involves  the  limbs,  and  this 
weakness  and  relaxation  prevent  accurate  adaptation  of  the  valve  seg- 
ments. He  urges  in  support  the  inconstant  character  of  the  murmur, 
appearing  and  disappearing  without  apparent  cause,  and  states  that  it 
may  be  synchronous  both  in  its  time  of  arrival  and  duration  with  the 
paresis  of  the  voluntary  muscles.  I  have  not  been  able  to  trace  any 
such  connection,  nor  have  I  found  in  the  paretic  cases  any  special  ten- 
dency to  variability  in  the  murmur.  Indeed,  so  far  as  my  experience 
goes,  the  apex  systolic  bruit  of  chorea  is  by  no  means  an  inconstant  mur- 
mur. If  muscular  incompetency  has  anything  to  do  with  the  production 
of  the  choreic  bruit,  it  is  more  likely  to  be  of  a  similar  character  to  that 
which  occurs  in  anaemia,  debility,  and  fevers.  Here  it  is  the  relaxation  of 


OSLER,   THE   CARDIAC    RELATIONS   OF    CHOREA.  875 


the  walls,  and  particularly  the  so-called  mitral  muscle,  which  induces  a 
condition  of  relative  insufficiency  of  the  segments  and  permits  of  regurgi- 
tation. There  may  be  in  chorea,  as  is  well  known,  a  high  degree  of 
anaemia,  and  in  a  certain  proportion  of  the  cases  this  explanation  of  the 
murmur  may  hold  good,  but  in  the  great  majority  of  instances  the  bruit 
is  detected  early  when  there  is  neither  anaemia  nor  debility. 

I  am  strongly  of  the  opinion  that  the  apex  systolic  bruit  of  chorea  is, 
in  at  least  nine  out  of  ten  cases,  associated  with  endocarditis : 

1 .  The  extraordinary  frequency  with  which  mitral  valvulitis  is  met 
with  in  fatal  cases.  There  is  no  known  disease  in  which  endocarditis  is  so 
constantly  found,  post-mortem,  as  chorea.  As  the  figures  above  quoted 
show,  it  is  exceptional  to  find  the  heart  healthy.  I  do  not  know  of 
statistics  of  any  very  large  number  of  fatal  cases  of  acute  articular  rheu- 
matism to  place  beside  these  figures,  but  I  doubt  if  even  this  disease, 
so  prone  to  endocardial  complication,  can  be  compared  with  chorea  in 
this  respect.  Dickinson  has  raised  the  question  whether  these  beads  of 
fibrin  are  not  rather  the  consequence  than  the  cause  of  the  valvular 
defect,  and  Sturges  holds  that  this  appearance  does  not  represent  a  true 
inflammation  of  the  endocardium.  Whether  a  true  inflammation  or 
not,  I  think  it  must  be  conceded  that  the  lesion  is  identical,  microscopi- 
cally as  well  as  macroscopically,  with  simple  or  warty  endocarditis  as  we 
see  it  in  other  diseases. 

2.  The  character  and  location  of  the  murmur  are  such  as  experience 
in  other  affections  has  taught  us  are  associated  with  inflammation  of  the 
mitral  segments.  I  speak  of  the  apex  bellows-murmur.  Why  this 
should  be  so  generally  associated  with  the  presence  of  a  row  of  small 
warty  vegetations  just  within  the  auricular  margins  of  the  curtains,  not, 
one  would  think,  seriously  interfering  with  their  functions,  is  a  problem 
to  be  solved.  The  condition  certainly  does  not  necessitate  regurgitation, 
and  the  bruit  may  perhaps,  as  has  been  suggested,  be  due  to  friction  of 
the  roughened  faces  of  the  segments. 

3.  The  inconstancy  of  the  murmur  and  its  disappearance  on  the 
subsidence  of  the  chorea  have  been  urged  against  this  view.  Now  we 
must  acknowledge  that  the  bruit  may  be  variable  and,  indeed,  does  not 
necessarily  accompany  mitral  endocarditis.  Kirkes,  years  ago,  insists  1 
upon  this,  and  there  have  been  two  autopsies  in  carefully  studied  cases 
of  chorea  in  which  the  vegetations  were  found  post-mortem,  and  careful 
examination  failed  to  reveal  a  murmur  (Baxter:  Brain,  vol.  ii.:  Frank. 
Allg.  Wiener  med.  Zeitung,  1879,)  The  facts  which  I  shall  subsequently 
give  suggest  that  we  may  during  the  attack  have  an  endocarditis,  not 
manifest  even  by  a  murmur,  but  which  has  laid  the  foundation  of  future 
trouble.  The  disappearance  of  the  apex  murmur  of  chorea — and  of 
rheumatism  too — has  been  repeatedly  followed,  and  if  caused  by  the 
small  vegetations,  this  is  a  natural  sequence  of  the  changes  which  go  on 


376    OSLER,  THE   CARDIAC   RELATIONS   OF  CHOREA. 


in  them.  At  first  a  soft  granulation  tissue,  they  become  in  time  firmer, 
smaller,  and  ultimately  smooth  flat  elevations  mark  the  spots.  It  is  not 
improbable  that  if  we  could  follow  accurately  the  auscultatory  history 
of  a  valve  affected  with  acute  endocarditis,  we  should  find  in  many  cases 
that  the  murmur  of  the  fresh  attack  disappeared,  to  reappear  when 
the  changes,  which  it  is  the  misfortune  of  the  acute  disease  to  initiate, 
have  reached  a  point  of  interfering  with  the  competency  of  the  valve. 

4.  In  its  sequel  the  cardiac  affection  of  chorea  has  been  supposed  to 
differ  from  that  of  other  diseases,  "as  none  of  the  injurious  after-conse- 
queuces  which  attend  endocarditis  in  its  other  relations  .  .  .  are 
found  to  ensue  here"  (Sturges).  A  study  of  any  large  number  of 
choreics  some  years  subsequent  to  the  disease  tells,  as  I  shall  show,  a  sad 
tale  to  the  contrary  and  proves  that  the  primary  heart  trouble  is,  in  a 
majority  of  cases,  at  least,  endocarditis. 

II.  The  Condition  of  the  Heart  in  Choreic  Patients 
some  Years  after  the  Attack. 

Owing,  doubtless,  to  the  difficulties  inherent  to  such  an  investigation,  this 
line  of  inquiry  has  not  been  followed  by  many  workers.  Indeed,  so  far 
as  I  know,  Dr.  Stephen  Mackenzie's  paper,  at  the  London  International 
Congress,  is  the  only  one  which  has  dealt  with  the  subject,  and  he  has 
examined  thirty-three  patients  at  periods  from  one  to  five  years  subse- 
quent to  the  attack.  Postal  cards  were  sent  to  all  the  choreic  patients,  in 
sets  of  twenty-five,  who  had  been  in  attendance  at  the  Infirmary  since 
1876,  asking  them  to  return  for  the  purpose  of  having  the  heart  exam- 
ined. One  hundred  and  ten  came  back,  a  number  much  exceeding  our 
expectations.1  All  the  more  recent  cases  in  attendance  at  the  clinics 
have  been  excluded — all,  indeed,  after  March,  1885,  so  that  the  study  is 
based  upon  110  cases  in  which  the  examination  was  made  more  than  two 
years  subsequent  to  the  attack  of  chorea.  In  each  case,  as  it  came, 
reference  was  made  to  the  original  notes,  questions  asked  concerning 
subsequent  attacks,  and  rheumatism,  and  the  heart  examined  in  the  re- 
cumbent and  erect  postures,  at  rest  and  after  exertion. 

The  results  summarized,  are  as  follows :  In  43  cases  the  heart  was 
normal,  in  54  there  were  signs  of  organic  disease,  and  in  13  there  was 
functional  disturbance. 

The  tables  which  I  have  prepared  are  too  full  for  publication,  but  the 
following  abstracts  of  the  cases  affected  will  be  of  interest : 

1871  (sixteen  years).    Two  cases. 

Case  I. — Laura  C.  R.,  aged  twenty-five.  Several  attacks  subsequent 
to  1871.    Never  had  rheumatism  until  February,  1887.    No  note  of 

1  It  speaks  well  for  the  stability  of  the  artisan  class  in  Philadelphia  that  so  many  of  the  postal  cards 
reached  their  destination.  Comparatively  few  were  returned  from  the  Post-office  with  the  comment — 
Removed;  cannot  find. 


OSLER,  THE   CARDIAC   RELATIONS   OF    CHOREA.  377 


heart  condition  in  previous  attacks.  Has  attacks  of  shortness  of  breath. 
Status prcesens :  Impulse  is  forcible.  Dulness  increased.  Apex  systolic 
murmur  heard  to  posterior  axillary  fold.    Second  left  accentuated. 

Case  II. — Kate  L.,  aged  twenty-one.  Two  or  three  attacks  after 
1871 ;  bad  one  in  1878.  In  1882,  had  inflammatory  rheumatism,  never 
any  joint  trouble  before  this  time.  In  1878,  note  is  "impulse  strong; 
apex  murmur."  She  has  had  attacks  of  shortness  of  breath.  Status 
prcesens:  Feeble  thrill;  localized  purring  presystolic  murmur.  Loud 
apex  systolic  transmitted  to  posterior  axillary  fold.  Second  left  accen- 
tuated. 

1872  (fifteen  years).    One  case.    No  heart  affection. 

1874  (thirteen  years).    Three  cases. 

Case  IV. — Annie  M.,  aged  twenty-five.  Second  attack  in  1883, 
third  in  1885.  Had  rheumatism  just  before  the  first  attack.  No  note 
of  heart  in  first  or  second  ;  in  1885,  an  apex  systolic  murmur.  Status 
prcesens :  Loud  apex  systolic  transmitted  to  axilla  ;  second  left  accentu- 
ated ;  transverse  dulness  increased ;  impulse  forcible. 

Case  V. — Bertha  G.,  aged  twenty-five.  A  second  attack  in  1880. 
No  rheumatism.  In  1880,  a  soft  systolic  murmur.  Status  prcesens :  Im- 
pulse not  forcible.  Loud  apex  systolic  murmur  propagated  to  axilla. 
Very  ringing  and  accentuated  second  left.  Has  palpitation  and  attacks 
of  shortness  of  breath. 

Case  VI. — Charles  M.,  aged  twenty-eight.  Second  attack  in  1880. 
Had  pains  in  joints  before  second  attack.  No  note  of  heart.  Is  strong 
and  well,  no  subjective  symptoms.  Status  prcesens :  Soft  apex  systolic 
murmur,  not  heard  in  axilla  or  in  pulmonary  area.  No  increase  in 
dulness.    Second  left  accentuated. 

1875  (twelve  years).    Two  cases  ;  one  normal. 

Case  VII. — Hester  G.,  aged  twenty.  Original  attack  very  severe ; 
a  second  in  1879,  and  one  since.  No  rheumatism.  No  note  of  heart  in 
attacks.  For  two  years  has  had  attacks  of  palpitation  and  dyspnoea. 
Status  prcesens :  Impulse  forcible.  Presystolic  thrill ;  rough  presystolic 
murmur.    Loud  accentuated  second  left. 

1876  (eleven  years).    Eight  cases  ;  one  normal. 

Case  IX. — Annie  T.,  aged  seventeen.  Since  1876  three  attacks,  last 
in  1885.  No  rheumatism.  In  1885,  a  soft  systolic  murmur.  Com- 
plains that  she  does  not  lie  comfortably  on  left  side.  Status  prcesens : 
Impulse  forcible,  outside  nipple.  Apex  systolic  loud,  heard  well  in 
axilla.    Second  left  accentuated. 

Case  X. — Robert  P.,  aged  twenty-one.  Second  attack  in  1879.  No 
rheumatism.  No  previous  note  of  neart.  Status  prcesens :  Action  rapid, 
impulse  diffuse.  Dulness  not  increased.  Blowing  systolic  murmur  just 
above  apex,  not  heard  in  axilla  ;  disappears  on  exertion.  Second  left 
accentuated. 

Case  XI. — Lizzie  H.,  aged  sixteen.  Many  attacks  since  1S7(>.  two 
of  them  severe.  Had  rheumatism  when  four  years  old.  In  1878, 
second  left  was  reduplicated.  Stafas  pnesens :  No  evident  enlargement 
of  heart ;  impulse  feeble ;  no  thrill.  At  apex  double  murmur,  presys- 
tolic short,  not  rough.    Systolic  not  loud,  not  transmitted  to  axilla.  On 


378    OSLER,  THE   CARDIAC   RELATION'S    OF  CHOREA. 


exertion  louder.  Both  very  distinct.  Second  left  very  loud.  Has 
occasional  attacks  of  palpitation. 

Case  XII. — Ida  L.,  aged  eighteen.  Three  attacks  since  1876.  No 
rheumatism.  No  note  of  heart  in  1879.  No  symptoms.  Status  prcesens  : 
Beat  forcible ;  dulness  increased.  Loud  apex  systolic  murmur,  heard 
at  angle  of  scapula  and  very  distinct  along  left  margin  of  sternum.  At 
aortic  cartilage  a  soft  systolic  bruit.  Second  left  ringing  and  accen- 
tuated. 

Case  XIV. — Jennie  A.,  aged  twenty.  Second  attack  in  1878,  third 
in  1879.  No  rheumatism.  In  1879,  sound,  stated  to  be  normal.  Status 
prcesejis :  Impulse  not  forcible,  no  apparent  enlargement.  In  fourth  left 
space  a  rough  presystolic  murmur;  limited  in  area.  At  apex  a  systolic 
bruit,  transmitted  to  axilla,  and  heard  at  angle  of  scapula.  Second  left 
very  accentuated.  Sounds  at  apex  booming.  No  symptoms,  always 
good  health. 

Case  XV. — Annie  L.,  aged  twenty-four.  Two  attacks  since,  last  one 
in  1882,  when  for  the  first  time  she  had  rheumatism.  No  note  of  heart. 
Status  prcesens :  Apex  an  inch  outside  nipple.  Impulse  forcible.  No 
thrill.  Presystolic  murmur,  not  rough,  in  fourth  space ;  apex  systolic, 
heard  in  axilla  and  at  angle  of  scapula.  Loudly  accentuated  second 
left.  Has  had  palpitation  and  shortness  of  breath  on  exertion  for  three 
years. 

Case  XVI. — Miriam  C,  aged  nineteen.  Two  attacks  since.  Never 
had  rheumatism.  Has  had  heart  disease  for  some  years ;  is  now  in  bed 
with  it. 

1877  (ten  years).    Seven  cases ;  three  affected. 

Case  XVII. — Andrew  G.,  aged  twenty-one.  The  attack  followed 
acute  rheumatism.  In  1878,  a  soft  systolic  murmur.  No  symptoms. 
Status  prcesens :  When  recumbent  sounds  clear.  Erect  and  after  exer- 
cise well-marked  apex  systolic,  not  transmitted.  Second  left  ringing, 
accentuated,  and  reduplicated.    No  enlargement  of  the  heart. 

Case  XX. — Mamie  L.,  aged  fifteen.  Rheumatism  (acute)  four  weeks 
before  onset  of  chorea  in  1877.  No  attack  since.  In  1877,  "  mitral 
murmur."  No  symptoms.  Status  prcesens  :  Impulse  forcible,  beat  out- 
side nipple  line.  Transverse  dulness  increased.  Loud  apex  systolic 
murmur,  propagated  to  posterior  axillary  fold.  Second  left  very  accen- 
tuated. 

Case  XXIII. — Rose  McF.,  aged  twenty-four.  Attack  in  1877  pro- 
longed and  severe ;  none  since.  No  rheumatism.  In  1877,  a  faint  apex 
systolic  murmur.  Status  prcesens :  Heart's  action  violent ;  impulse  for- 
cible ;  apex  outside  nipple.  Marked  presystolic  thrill.  Presystolic  mur- 
mur in  fourth  interspace.  Systolic  murmur  in  fifth  space,  and  heard  as 
far  as  posterior  axillary  fold.  Second  sound  accentuated  at  the  second 
left  cartilage,  and  also  heard  loudly  in  axilla.  Patient  is  at  times  very 
short  of  breath  ;  has  attacks  of  palpitation  and  has  fainted. 

1878  (nine  years).    Two  cases ;  one  affected. 

Case  XXIV.— Minnie  C,  aged  fifteen.  Attacks  also  in  1879,  '80, 
and  '85.  Rheumatism  in  1885,  never  before.  In  1878  an  apex  systolic 
murmur.  No  symptoms.  Status  prcesens:  Impulse  forcible;  apex  out- 
side nipple-line ;  transverse  dulness  increased.    Apex  systolic  murmur 


OSLER,  THE   CARDIAC    RELATIONS   OF    CHOREA.  379 


heard  to  posterior  axillary  fold.  Double  murmur  at  aortic  cartilage ; 
diastolic  heard  also  on  sternum.    Second  left  not  accentuated. 

1879  (eight  years).    Four  cases;  all  affected. 

Case  XXVI. — Fannie  N.,  aged  fifteen.  Second  attack  in  1885.  Has 
had  rheumatic  pains,  but  no  swelling  of  joints.  In  1879  had  pain  about 
the  heart,  and  since  then  has  had  occasional  attacks  of  palpitation  on 
exertion.  Status  prsceens :  Impulse  in  fifth  a  little  out.  Transverse 
dulness  increased.  Presystolic  thrill,  most  marked  at  apex.  Rough 
presystolic  murmur  at  and  just  above  the  apex.  Soft  systolic  at  and 
outside  apex  beat,  Second  left  much  accentuated,  and  is  also  very  ring- 
ing and  loud  in  axilla  and  at  angle  of  scapula. 

Case  XXVII. — Lizzie  R.,  aged  twelve.  Three  subsequent  attacks, 
1880,  '83,  and  '86.  Those  of  1879,  '80,  and  '83  very  severe.  No  rheuma- 
tism. No  previous  note  of  heart  condition.  Has  had  no  heart  symptoms. 
Status  prcesens :  Forcible,  diffuse  impulse.  Apex  a  little  outside  nipple. 
Systolic  murmur  at  apex  transmitted  to  axilla  and  heard  feebly  at  angle 
of  scapula.    Second  left  very  accentuated. 

Case  XXVIII. — Rose  F.,  aged  thirteen.  Second  attack  in  1881. 
Heart  normal  in  1879.  Has  been  short  of  breath,  particularly  on  exer- 
tion. Status  pnesens:  Impulse  strong.  Transverse  dulness  increased. 
Rough  presystolic  thrill.  Very  rasping  presystolic  bruit,  Maximum 
intensity  in  fifth,  just  within  nipple.  Second  left  accentuated  and  re- 
duplicated.   Aortic  sounds  feeble. 

Case  XXIX. — Mary  G.,  aged  thirteen.  Several  attacks  since  1879 ; 
in  1885  a  bad  one,  and  now,  May,  1887,  is  in  infirmary  with  a  severe 
attack.  Rheumatism  in  1885  with  chorea,  not  before ;  and  this  time 
has  had  swollen  joints.  In  1885  had  systolic  apex  murmur.  Status 
prcesens:  Impulse  in  fifth  and  sixth,  outside  nipple.  Dulness  increased. 
Loud  apex  systolic  bruit  propagated  to  axilla  and  scapula.  Second  left 
much  accentuated.  Has  had  attacks  of  cardiac  dyspnoea  in  which  she 
could  not  lie  down.    At  times  severe  pain  at  heart. 

1880  (seven  years).    Five  cases  ;  three  affected. 

Case  XXXII. — Ellen  McG.,  aged  twenty-three.  No  rheumatism. 
No  note  of  heart  in  1880.  Is  anaemic ;  has  palpitation,  shortness  of 
breath,  and  at  times  severe  pain  at  heart.  Status  prcesens :  Action  rapid 
and  forcible  ;  dulness  increased.  Presystolic  thrill  all  over  mitral  area. 
Rough  presystolic  murmur.  Soft  systolic  bruit  just  outside  apex.  Second 
left  is  loud  but  not  specially  accentuated.  Examined  again  some  weeks 
after  a  course  of  iron  and  arsenic,  which  had  relieved  the  anaemia  ; 
murmurs  unchanged. 

Case  XXXIII. — Angela  W.,  aged  eighteen.  Four  attacks  since  the 
first  in  1880.  No  rheumatism.  Heart,  in  1884,  said  to  be  normal. 
Has  had  pain  at  heart,  and  is  at  times  short  of  breath.  Statu*  prcesens: 
Impulse  forcible.  Soft  apex  systolic,  heard  as  far  as  middle  axilla,  and 
increased  on  exertion;  not  altered  by  position.  Second  left  a  little  ac- 
centuated. 

Case  XXXIV. — Florence  B.,  aged  twenty.  Rheumatism  six  months 
before  the  attack.  In  1880  an  apex  systolic  murmur.  Has  had  since 
then  occasional  attacks  of  palpitation.  Statu*  pnrxens :  Impulse  forcible ; 
apex  a  little  out,  but  no  special  enlargement.  Apex  systolic  murmur, 
heard  well  to  middle  axilla.    Marked  accentuation  of  second  left. 


380    OSLER,  THE   CARDIAC   RELATIONS  OF  CHOREA. 


1881  (six  years).    Sixteen  cases  ;  nine  affected. 

Case  XXXVI. — Louis  O.,  aged  seventeen.  At  least  five  attacks 
since  1881.  No  rheumatism.  No  note  of  heart.  No  symptoms.  Status 
prcesens:  Apex  beat  in  fourth  space  in  nipple  line,  heaving  and  for- 
cible ;  dulness  increased.  Loud  systolic  murmur  at  apex  heard  to  pos- 
terior axillary  fold,  but  not  above  fourth  space.  When  recumbent  it  is 
heard  in  second  and  third  spaces  as  well.   Second  left  very  accentuated. 

Case  XXXIX. — Frank  N.,  aged  thirteen.  A  second  attack  in  1884. 
No  rheumatism.  Heart  said  to  have  been  normal  in  1884.  For  some 
time  has  been  very  short  of  breath,  and  gets  tired  on  exertion.  Status 
prcesens:  Precordia  bulges.  Impulse  diffuse;  dulness  increased.  Pre- 
systolic thrill  iu  fourth  interspace.  A  blubbering  presystolic  murmur. 
Maximum  intensity  in  fourth  space.  Loud  blowing  systolic  bruit ;  heard 
also  in  axilla.    Very  accentuated  second  left.    Aortic  second  feeble. 

Case  XL. — William  P.,  aged  twelve.  Second  attack  in  1883,  third 
in  1885.  No  rheumatism.  Condition  of  heart  not  noted.  Has  no 
symptoms.  Status  prcesens:  Diffuse  apex  beat  in  nipple  line,  in  fourth 
and  fifth  spaces.  Transverse  dulness  increased.  In  erect  posture  sounds 
clear.  Recumbent,  distinct  apex  systolic  murmur  transmitted  along 
anterior  axillary  fold.  In  third  and  fourth  interspaces  double  murmur, 
the  diastolic  not  rough.    Second  left  very  much  accentuated. 

Case  XLI. — Joseph  M  ,  aged  thirteen.  First  attack  January,  1881 ; 
second,  October,  1881.  No  rheumatism.  In  1881  a  soft  systolic  mur- 
mur. Has  had  vertigo  and  rushes  of  blood  to  head.  Status  prcesens  : 
Impulse  not  forcible ;  dulness  slightly  increased.  No  thrill,  but  loud 
shock  of  first  sound.  Rumbling  presystolic  murmur,  maximum  in  fifth 
space  in  nipple  line,  is  well  heard  to  anterior  axillary  fold.  Loudly 
accentuated  second  left.    No  systolic  murmur  even  when  recumbent. 

Case  XLII. — Carrie  B.,  aged  .    Second  attack  in  1884  ;  third 

in  1886,  all  severe.  No  rheumatism.  In  1881  heart  normal.  No  symp- 
toms. Status  prcesens:  Visible,  somewhat  forcible,  pulsation  in  third, 
fourth,  and  fifth  spaces.  Erect  posture,  no  murmur;  recumbent,  systolic 
bruit  at  second  left,  localized.  Second  sound  here  loud,  sharp,  and 
reduplicated. 

Case  XLIII. — Mary  B.,  aged  sixteen.  Three  or  four  slight  attacks 
since  1881.  In  1881  pains  in  joints,  no  swelling.  In  1881  an  apex 
bruit.  Has  had  no  heart  symptoms.  Status  prcesens :  No  enlargement. 
When  erect,  sounds  clear ;  recumbent,  systolic  bruit  at  second  left,  with 
marked  accentuation  of  second  sound. 

Case  XLV. — Marcus  Van  A.,  aged  eleven.  None  since.  No  rheu- 
matism. In  1881  a  somewhat  loud  musical  bruit.  No  symptoms. 
Status  prcesens:  Apex  beat  in  nipple  line,  fifth  space.  Impulse  not 
specially  forcible.  Loud  blowing  systolic  bruit  at  apex,  propagated 
to  axilla  and  heard  well  at  scapula.  Second  left  accentuated  and  re- 
duplicated. 

Case  XLVI. — Alice  W.,  aged  seventeen.  Second  attack  in  1882. 
Pains  in  knees  in  1882,  and  lately  in  shoulders.  Heart  normal  in  1881 
and  1882.  Status  prcesens:  Soft  apex  systolic  murmur,  not  heard  in 
axilla.  Second  left  accentuated.  No  enlargement  of  heart.  Has  at 
times  palpitation  and  shortness  of  breath. 

Case  XLIX. — Jessie  J.,  aged  nineteen.  Three  attacks  since.  Rheu- 
matism with  attack  in  1883,  and  again  in  1885.    Heart  said  to  be 


OSLER,  THE   CARDIAC   RELATIONS  OF   CHOREA.  381 


normal  in  1885.  Status  prcesens:  Beat  in  fifth  space  outside  nipple. 
Dulness  increased.  At  apex  a  soft  systolic  bruit,  not  heard  in  axilla, 
except  after  exertion.  In  fourth  space,  in  localized  region,  a  soft  dias- 
tolic murmur,  not  increased  toward  sternum,  not  heard  at  aortic  or 
pulmonary  cartilages  ;  it  also  is  intensified  by  exertion.  Has  "  attacks 
at  the  heart,"  faints,  and  gets  cold.  Has  much  pain  at  times  and  is 
short  of  breath. 

1882  (five  years).    Thirteen  cases  ;  ten  affected. 

Case  L— Tillie  M.,  aged  fifteen.  Attacks  also  in  1883  and  1886. 
No  rheumatism,  but  lately  has  had  pains  in  shoulders.  No  note  of 
heart.  Has  had  at  times  pain  at  heart  aud  palpitation.  Status  prcesens : 
Apex  beat  just  within  nipple,  a  little  forcible.  Apex  systolic  bruit 
heard  along  anterior  axillary  fold  and  in  middle  axilla.  Second  left 
accentuated. 

Case  LII. — Annie  B.,  aged  eighteen.  No  rheumatism.  In  1882  a 
loud  apex  systolic  bruit.  Has  had  shortness  of  breath  and  palpitation. 
Status  prcesens:  Beat  forcible,  outside  nipple  line;  dulness  increased. 
Apex  systolic  murmur,  heard  also  iu  axilla  and  at  angle  of  scapula ; 
also  as  high  as  second  rib.    Second  left  loudly  accentuated. 

Case  LIII. — Mary  J.,  aged  fourteen.  Attacks  also  in  1883,  '84,  and 
'85.  No  rheumatism.  Heart  normal  in  1882.  No  symptoms.  Status 
prcesens:  Impulse  forcible.  Soft  systolic  bruit  at  apex,  heard  as  high 
as  third  space,  not  propagated  to  axilla.  Remarkable  accentuation  of 
second  left. 

Case  LIV. — Bessie  P.,  aged  thirteen.  Second  attack  in  1883.  Rheu- 
matism in  hands  and  feet  with  first  attack.  Heart  said  to  have  been 
normal.  Status  prcesens :  Impulse  forcible.  Apex  in  sixth  space  an  inch 
outside  nipple  line.  Slight  presystolic  rumble  at  apex.  Loud  systolic 
murmur  in  second  and  third  interspaces,  not  so  marked  at  apex.  Second 
left  loudly  accentuated.    No  symptoms. 

Case  LV. — Harriet  H.,  aged  eight.  No  rheumatism.  Died  of  heart 
disease  with  dropsy,  November  8,  1883. 

Case  LVII. — Sadie  C,  aged  twelve.  Second  attack  in  1885.  In 
1886  ankles  swollen  and  sore  ;  never  had  rheumatism  with  the  attacks 
of  chorea.  No  note  of  heart  in  1882.  In  1885  "  hypertrophied  and 
loud  apex  systolic  murmur."  Status  prcesens:  Apex  an  inch  outside 
nipple  line.  Impulse  forcible.  Dulness  increased.  No  thrill.  High- 
pitched  systolic  bruit  at  apex,  loud  also  in  axilla  and  at  angle  of  scapula. 
Very  accentuated  second  left.  Has  much  throbbing  of  heart  on  exer- 
tion, and  has  vomited  after  skipping. 

Case  LIX. — Maggie  W.,  aged  fifteen.  Second  attack  in  1885.  No 
rheumatism.  Heart  normal  in  1882.  Status  prcesens:  A  soft  murmur 
at  apex,  not  transmitted  ;  increased  on  holding  breath.  Second  left  very 
accentuated. 

Case  LX. — Fannie  S.,  aged  eleven.  Second  attack  in  1883,  third 
in  1884,  and  fourth  in  1885.  Rheumatism  in  1883;  severe  attack.  In 
November,  1882,  a  basic  systolic  murmur,  which  persisted  in  1884.  In 
June,  1885,  there  were  hypertrophy  and  evidence  of  aortic  and  mitral 
disease.    Died  of  cardiac  dropsy,  July  11,  1886. 

Case  LXI. — Catherine  B.,  aged  thirteen.  A  second  slight  attack  in 
spring  of  this  year.  No  rheumatism.  No  note  of  heart  in  1882.  Statu* 
prcesens:  Impulse  forcible,  at  and  a  little  outside  nipple  line.  Dulness 


382    OSLER,  THE   CARDIAC   RELATIONS   OF  CHOREA. 


increased.  Feeble  presystolic  thrill.  Loud  apex  systolic  murmur,  pro- 
pagated to  axilla.  In  fourth  space  just  within  nipple,  a  rumbling  pre- 
systolic murmur.  Second  left  very  accentuated.  Has  had  at  times 
severe  pain  in  heart ;  no  shortness  of  breath. 

1883  (four  years).    Fifteen  cases ;  eight  affected. 

Case  LXII. — James  G.,  aged  thirteen.  Second  attack  in  1885,  third 
in  1886.  No  acute  rheumatism  ;  pains  in  shoulder.  In  1886  a  systolic 
apex  murmur.  Status  prcesens :  Apex  outside  nipple  line ;  large  area  of 
forcible  impulse  in  fourth  and  fifth  spaces.  Transverse  dulness  increased. 
No  thrill.  High-pitched  apex  systolic  murmur  transmitted  to  axilla 
and  angle  of  scapula.  In  fourth  space  a  faint  rumble  before  first  sound ; 
second  left  accentuated  and  reduplicated.    Has  no  heart  symptoms. 

Case  LXIII.  — Tinnie  JB.,  aged  twelve.  Second  attack  in  1884,  third 
in  1886.  No  rheumatism.  In  1886  well-marked  cardiac  lesions.  Status 
prcesens:  Apex  beat  forcible,  outside  nipple  line.  Dulness  increased. 
Loud,  rough  apex  systolic  bruit,  transmitted  to  scapula;  second  left 
accentuated  and  reduplicated.    Has  pain,  and  at  times  palpitation. 

Case  LXIV. — Henrietta  K.,  aged  twenty-one.  Second  attack  in 
1884.  No  rheumatism.  In  1883  heart's  action  intermittent.  Status 
prcesens:  Beat  forcible.  No  thrill.  Loud,  rough  apex  systolic  bruit 
heard  at  angle  of  scapula.  Second  left  much  accentuated.  Has  great 
shortness  of  breath  on  exertion. 

Case  LXV. — Lorenzo  D'A.,  aged  eleven.  Two  slight  returns.  No 
rheumatism.  No  note  of  heart  in  1883.  Status  prcesens :  Impulse  slow, 
forcible  ;  apex  in  fifth  space,  in  nipple  line.  Soft  apex  systolic  murmur, 
louder  on  exertion  ;  not  heard  at  mid  axilla.  Second  left  much  accen- 
tuated and  reduplicated.    Has  distress  at  heart  on  exertion. 

Case  LXV  I. — Nellie  H.,  aged  nine.  Second  attack  in  1884,  third 
in  1885.  No  rheumatism.  No  note  of  previous  heart-condition.  Status 
prcesens :  Apex  beat  diffuse,  maximum  in  sixth  space,  one  inch  outside 
nipple  line.  Dulness  increased.  No  thrill.  Loud  apex  systolic  murmur 
transmitted  to  angle  of  scapula.  Just  below  and  inside  the  nipple  a  soft 
presystolic  bruit.  Second  left  much  accentuated.  In  December,  1886, 
the  child  had  a  sharp  attack  of  cardiac  dyspnoea. 

Case  LXVII. — Edward  R.,  aged  twelve.  Second  attack  in  1885. 
No  clear  history  of  rheumatism ;  has  had  pains.  No  note  of  heart. 
Status  prcesens :  Beat  in  fifth,  just  outside  nipple  line.  Dulness  increased. 
Just  above  apex,  in  localized  region,  a  presystolic  murmur ;  louder  in 
recumbent  posture.  When  breath  is  held,  soft  apex  systolic  murmur. 
Second  left  much  accentuated. 

Case  LXXI. — Annie  C,  aged  eleven.  Bad  attack  for  a  month ;  no 
recurrence.  No  rheumatism.  No  note  of  heart  in  1883.  Status  prcesens  : 
Beat  at  nipple,  in  fourth  space.  Transverse  dulness  increased.  Feeble 
thrill  above  apex.  Rough  presystolic  murmur  in  third  and  fourth 
spaces ;  heard  also  along  pectoral  fold.  Just  outside  apex  a  soft 
systolic.   Loudly  accentuated  second  left.  Is  short  of  breath  on  exertion. 

Case  LXXIV. — William  H.,  aged  fifteen.  Still  has  twitches  at 
times.  No  rheumatism.  No  note  of  heart.  Status  prcesens:  Apex 
beat  in  nipple  line.  Dulness  increased.  Feeble  presystolic  thrill  at 
apex.  In  second  left  interspace  a  loud,  rough,  systolic  murmur.  In 
third  and  fourth  spaces  a  softer  bruit.  Distinct  presystolic  rumble 
above  apex  beat.    First  sound  reduplicated  at  apex.    Second  left  much 


OSLEK,  THE   CARDIAC   RELATIONS   OF  CHOREA 


383 


accentuated.  Has  what  his  mother  calls  "  asthma  spells,"  particularly 
on  exertion, 

1884  (three  years).    Thirteen  cases  ;  ten  affected. 

Case  LXXYII. — Harry  B.,  aged  thirteen.  Second  attack  in  1885, 
third  in  1886.  Rheumatism  with  attack  in  1884.  Apex  murmur  in 
1886.  Status  prcesens :  Impulse  feeble,  just  inside  nipple  line.  No 
thrill.  Dulness  not  increased.  Soft  apex  systolic  bruit ;  heard  well  to 
mid-axilla.  Rough  presystolic  murmur,  maximum  intensity  at  apex. 
Both  intensified  after  exertion.  Loudly  accentuated  and  reduplicated 
second  left.  Xo  palpitation ;  no  shortness  of  breath.  Cheeks  are 
flushed,  and  he  has  a  cardiac  look. 

Case  LXXVIII. — Ida  M.,  aged  fourteen.  Xo  other  attack.  Xo 
rheumatism.  Xo  note  of  heart.  Status  prcesens •:  Xo  enlargement.  Soft 
apex  systolic  bruit  propagated  along  anterior  axillary  fold.  Systolic 
murmur  at  second  left  space.  Loudly  accentuated  left.  Has  no 
symptoms. 

Case  LXXIX. — George  G.,  aged  thirteen.  Xo  other  attack.  Had 
pain  in  left  hip  in  1884.  Heart  normal.  Status  prcesens:  Xo  enlarge- 
ment. Soft  apex  systolic  bruit ;  hot  heard  in  axilla,  but  well-marked 
in  third  left  apex.  Second  left  very  accentuated,  and  the  diastolic  shock 
here  loud. 

Case  LXXX; — Xellie  M.,  aged  eleven.  Right  knee  was  swollen. 
Xo  note  of  heart.  Status  prcesens :  Forcible  apex  beat  in  fifth  space, 
one  inch  outside  nipple  line.  Dulness  increased.  At  apex  first  sound 
booming  and  echoing.  In  third  and  fourth  left  spaces  loud  systolic 
bruit ;  feeble  at  second  left  cartilage ;  not  audible  in  axilla ;  faintly 
heard  in  mid-sternum.  Much  accentuated  second  left.  Has  no 
symptoms. 

Case  LXXXII  — John  D.,  aged  eighteen.  Second  slight  attack  in 
1886.  In  1887  slight  rheumatism.  In  1884  soft  murmur  at  base. 
Status  prcesens :  Impulse  just  within  ni{)ple.  Dulness  increased.  Xo 
thrill.  At  apex  a  rumbling  presystolic  murmur.  Xo  systolic  bruit 
audible  at  apex.  At  fourth  left  and  up  and  down  the  sternum  is  a  long- 
drawn  diastolic  murmur,  of  maximum  intensity  on  sternum,  opposite 
fourth  cartilage.  Heard  at  aortic  cartilage  and  at  xiphoid.  Xo  aortic 
systolic  bruit.  Second  left  very  accentuated.  Posture  did  not  alter  the 
murmurs.    He  had  no  heart  symptoms. 

Case  LXXXIII. — Kate  H.,  aged  fifteen.  Rheumatism  very  badly 
at  the  time.  Heart  said  to  be  normal.  Status  prcesens :  Apex  beat  for- 
cible, outside  nipple  line.  Cardiac  shock  over  a  large  area.  Xo  thrill. 
Loud  apex  systolic  murmur  propagated  along  anterior  axillary  told. 
Second  left  much  accentuated.    Has  no  heart  symptoms. 

Case  LXXXIV. — Henry  M.,  aged  fifteen.  Xo  rheumatism.  Heart 
normal  in  1884.  Status  prcesens:  Impulse  diffuse  in  fourth  and  sixth 
spaces,  one  inch  outside  nipple  line.  First  sound  at  apex  booming. 
When  recumbent  a  soft  systolic  murmur  in  second  and  third  left  spaa  a 
near  sternum.    Second  left  much  accentuated. 

Case  LXXXVI. — Lillie  D.,  aged  twelve.  Xo  rheumatism.  Heart 
normal  in  1884.  Status  prcesens:  Xo  enlargement.  When  recumbent 
a  soft,  long,  apex  systolic  murmur,  not  heard  in  axilla  or  in  second  or 
third  spaces.  Disappears  when  erect.  Second  dull  and  loud,  not  sharp 
and  ringing,  like  second  right. 


384    OSLEE,   THE   CARDIAC   RELATIONS   OF  CHOREA. 


Case  LXXXVII. — Fannie  P.,  aged  ten.  Second  attack  in  1885. 
Pains  in  wrists,  but  no  swelling.  In  1885  apex  murmur,  presystolic ; 
soft  basic  murmur;  hypertrophy.  Status  prcesens:  Forcible  apex  beat 
in  fifth  space,  outside  nipple.  Feeble  thrill.  Loud,  high-pitched  apex 
systolic  bruit,  transmitted  to  scapula ;  and,  in  fact,  all  over  left  chest. 
Presystolic  bruit.  At  aortic  cartilage  a  rough,  systolic  murmur. 
Second  left  accentuated.    Has  palpitation  at  times. 

Case  LXXXIX. — Annie  T.,  aged  thirteen.  Several  slight  returns 
since  1884.  Rheumatism  three  months  after  the  chorea.  No  note  of 
heart  in  1884.  Status  prcesens:  Action  rapid,  apex  a  little  out  from 
nipple  line.  Dulness  increased.  Loud,  rough  systolic  bruit  at  apex, 
transmitted  to  scapula.  Second  sound  very  accentuated  at  third  left 
cartilage.  Has  "  spells"  with  her  heart ;  has  fainted.  Is  short  of  breath 
on  exertion. 

1885  (two  years).    Eighteen  cases  ;  five  affected. 

Case  XCI. — Lizzie  B.,  aged  fifteen.  Xo  attack  since.  Xo  rheuma- 
tism. No  note  of  heart.  Status  prcesens:  Impulse  strong.  Thrill  at 
apex.  Localized  systolic  murmur  at  apex,  not  heard  in  axilla  or  on 
third  or  second  spaces.    Loudly  accentuated  second  left. 

Case  XCII. — Alice  X.,  aged  ten.  Xo  rheumatism.  In  1885  loud 
mitral  systolic.  Status  prcesens :  Apex  beat  diffuse  in  fourth  and  fifth 
spaces  in  nipple  line.  Transverse  dulness  increased.  Apex  systolic 
murmur,  heard  beyond  mid-axilla ;  intensified  in  recumbent  posture. 
Marked  accentuation  of  second  left. 

Case  XCVII. — William  R.,  aged  nine.  Xo  rheumatism.  Heart  in 
1885  said  to  be  normal.  Status  prcesens :  Xo  enlargement.  First  sound 
not  clear,  and  on  exertion  a  soft  systolic  murmur  at  apex ;  heard  also 
two  inches  beyond  nipple,  and  as  high  as  third  rib.  Loudly  accentu- 
ated second  left.    Has  no  symptoms. 

Case  C. — Georgie  G.,  aged  thirteen.  Xo  rheumatism.  In  1885  a 
basic  systolic  murmur.  Status  prcesens :  Impulse  diffuse,  forcible ;  apex 
just  outside  nipple  line.  Dulness  increased.  Thrill.  At  apex  loud  sys- 
tolic bruit,  propagated  to  posterior  axillary  fold.  Second  left  dull,  thud- 
ding, and  accentuated.  Heart's  action  irregular.  Has  palpitation  and 
shortness  of  breath. 

Case  CI. — Jennie  X.,  aged  nine.  Secoud  attack  in  1886,  in  which 
she  had  rheumatism.  Heart  in  1885  normal.  In  1886  loud  apex  sys- 
tolic murmur.  Status  prcesens:  Impulse  forcible,  apex  in  nipple  line. 
Dulness  increased.  Apex  systolic  transmitted  to  axilla  arid  angle  of 
scapula ;  heard  also  as  high  as  second  rib.  Second  left  loudly  accentu- 
ated.   Has,  at  times,  throbbing,  palpitation,  and  pain. 

Of  the  43  cases  in  which  the  heart  was  found  normal,  12  had  had 
three  or  more  attacks,  8  had  had  two,  and  23  a  single  attack.  There 
was  a  history  of  rheumatism  in  8 — i.  e.,  18.6  per  cent.  In  6  of  these 
cases  the  rheumatism  was  acute.  In  only  2  cases  had  there  been  a  mur- 
mur noted  at  the  time  of  the  original  attack. 

From  the  cases  presenting  abnormal  physical  signs,  13  may  be 
separated  as  examples  of  functional  trouble.  They  are  cases  without 
signs  of  enlargement  of  the  heart  and  with  localized  or  variable  mur- 
murs.   Ten  presented  soft  apex  systolic  bruits  not  propagated,  in  3 


OSLER,  THE  CARDIAC    RELATIONS   OF   CHOREA.  385 

variable  with  position.  In  most  of  these  there  was  accentuation  of  the 
second  left  pulmonary  sound,  but  I  do  not  think  much  stress  is  to  be 
placed  upon  this  sign  in  young  .persons,  as  it  is  by  no  means  uncommon 
in  normal  hearts.  Particular  attention  was  paid  to  this  point  in  the 
examination  of  all  the  cases  and  comparison  made  between  the  sounds 
in  the  second  right  and  second  left  spaces.  There  were  10  normal  cases 
in  which  the  pulmonary  sound  was  distinctly  louder  than  the  aortic,  and 
in  some  instances  reduplicated.  No  note  was  taken  of  the  murmurs,  so 
often  developed  in  the  region  of  the  pulmonary  artery  during  respira- 
tion and  which  are  extremely  common  in  thin-chested  children.  In  2 
cases  the  sounds  in  this  region  were  clear  in  the  erect  posture,  but  in  the 
recumbent  position  systolic  bruits  developed  ;  in  both  the  second  sound 
was  accentuated,  and  in  one  the  area  of  pulsation  somewhat  increased. 
In  a  third  case  there  was  a  soft  systolic  murmur  in  the  second  and  third 
spaces  in  the  recumbent  position  only,  with  accentuation  of  the  pul- 
monary sound  and  the  apex  beat  outside  the  nipple  line.  In  some  of 
these  there  may  have  been  organic  changes  in  the  valves,  but  I  deemed 
it  best  to  exclude  all  doubtful  cases. 

There  remain  for  consideration  54  cases  with  signs  of  valve  disease. 
In  21  cases  there  had  been  three  or  more  attacks  of  chorea. 

The  facts  regarding  rheumatism  are  interesting.  In  22  cases,  40.7  per 
cent.,  there  was  a  distinct  history  of  articular  trouble,  sometimes  with 
the  chorea,  but  in  6  cases  from  one  to  five  years  after  the  attacks. 
Comparing  the  frequency  of  rheumatic  affection  in  this  group,  40.7  per 
cent.,  with  that  in  the  total  number  of  cases,  15  per  cent.,  or  with  the 
group  of  43  normal  cases,  18.6  per  cent.,  we  see  the  influence  this 
disease  exercises  in  producing  the  heart  lesions.  We  have,  however, 
the  larger  proportion,  59.3  per  cent.,  of  the  cases  without  any  history  of 
rheumatic  trouble.  Of  the  21  cases  which  had  had  three  or  more 
attacks  of  chorea,  only  7  had  rheumatism. 

In  this  group  there  are  rather  more  than  3  females  to  1  male,  a  pro- 
portion considerably  greater  than  in  the  total  number  of  cases. 

With  reference  to  the  nature  and  seat  of  the  lesion,  there  were  44 
cases  of  uncomplicated  mitral  affection  and  4  instances  of  combined 
aortic  and  mitral  disease.  In  25  cases  there  was  a  mitral  systolic  mur- 
mur ;  in  17  a  distinct  presystolic  murmur,  with  or  without  a  thrill,  and 
usually  with  a  systolic  bruit.  Of  the  aortic  lesions  Case  XII.  pre- 
sented a  soft  aortic  direct  murmur  and  a  mitral  systolic ;  Case  XXIV. 
a  double  aortic  murmur  as  well  as  a  mitral  systolic ;  Case  LX.  died  of 
combined  aortic  and  mitral  disease  ;  Case  LXXXII.  presented  the 
unusual  combination  of  an  aortic  diastolic  and  a  mitral  presystolic 
murmur.  The  overwhelming  proportion  of  cases,  with  mitral  lesions, 
is  what  we  might  expect  from  the  constancy  with  which  the  acute 
endocarditis  of  rheumatism  and  chorea  attacks  these  valves 

NO.  CLXXXVIII. — OCTOBER,  1887.  25 


386 


DANA,   HEREDITARY  TREMOR. 


There  are  many  points  of  interest  in  physical  diagnosis  which  these 
cases  illustrate,  but  I  am  only  concerned  now  with  the  clinical  problem 
of  the  frequency  with  which  organic  heart  disease  follows  chorea. 

Not  many  of  the  cases  had  subjective  symptoms  of  cardiac  disease. 
In  14  instances  there  wras  complaint  of  shortness  of  breath;  16  cases 
had  attacks  of  palpitation,  and  in  6  cases  there  was  cardiac  pain.  Two 
cases  had  died  of  heart  disease,  1  was  in  bed  with  cardiac  dropsy,  and 
in  several  others  there  were  premonitions  of  heart  failure.  The  majority 
illustrated  the  importapt  clinical  law  in  valvular  disease,  that  the  symp- 
toms do  not  result  from  the  lesion,  but  from  failure  in  the  compensatory 
action  which  for  years  may  equalize  the  circulation  and  obviate  com- 
pletely the  most  serious  mechanical  defect. 

A  study  of  these  cases  justifies,  I  think,  the  following  conclusions : 

1.  That  in  a  considerable  proportion  of  cases  of  chorea — much  larger 
than  has  hitherto  been  supposed — the  complicating  endocarditis  lays  the 
foundation  of  organic  heart  disease. 

2.  In  a  majority  of  the  cases  the  cardiac  affection  is  independent  of 
rheumatism,  and  cannot  be  regarded  as  in  any  way  associated  with  it ; 
unless,  indeed,  we  hold  with  Bouillaud,  that  in  the  disease  "  chez  les 
jeunes  sujets  le  coeur  se  comporte  comme  une  articulation." 

3.  As  the  presence  of  an  apex  systolic  murmur  in  chorea  is  usually 
an  indication  of  the  existence  of  mitral  valvulitis,  as  much  care  should 
be  exercised  in  this  condition  as  in  the  acute  endocarditis  of  rheumatism. 
Rest,  avoidance  of  excitement,  and  care  in  convalescence,  may  do  much 
to  limit  a  valvulitis,  and  obviate,  possibly,  the  liability  to  those  chronic 
nutritional  changes  in  the  valves  wherein  lies,  after  all,  the  main  danger. 


HEKEDITAKY  TKEMOR, 

A  HITHERTO  TJNDESCRIBED  FORM  OF  MOTOR  NEUROSIS.1 

By  C.  L.  Dana,  A.M.,  M.D., 

PRESIDENT  OF  THE  NEW  YORK  NEUROLOGICAL  SOCIETY,  VISITING  PHYSICIAN  TO  BELLEVUE  HOSPITAL, 
PROFESSOR  OF  NERVOUS  AND  MENTAL  DISEASES,  NEW  YORK  POST-GRADUATE 
MEDICAL  SCHOOL. 

The  object  of  this  paper  is  to  call  attention  to  a  peculiar  hereditary 
motor  disorder  which  has  heretofore  never  to  my  knowledge  been 
systematically  described  by  medical  writers. 

Definition. — The  affection  in  question  consists  of  a  fine  tremor,  con- 


1  I  am  under  great  obligations  to  Dr.  Henry  Boynton  and  Dr.  Fred.  T.  Kidder,  of  Woodstock,  Vt.r 
and  to  Dr.  Coulard,  of  Brattleboro,  Vt.,  for  assistance  in  securing  data  for  my  histories. 


DANA,  HEREDITARY  TREMOR. 


387 


stantly  present  in  typical  cases  during  waking  hours,  voluntarily  con- 
trolled for  a  brief  time,  affecting  nearly  all  the  voluntary  muscles, 
chronic,  beginning  in  very  early  life,  not  progressive,  not  shortening 
life,  not  accompanied  with  paralysis  or  any  other  disturbances  of  nervous 
function.  It  resembles  to  some  extent  the  tremor  of  paralysis  agitans, 
still  more  a  simple  neurasthenic  tremor.  A  most  striking  clinical  feature 
is  its  marked  hereditary  or  family  type,  and  its  transmission  along  with 
other  nervous  diseases. 

Historical. — Sauvages  (Nosolog.  meth.,  1766*  quoted  by  Reynolds's 
System  of  Med.,  iii.  p.  196)  refers  to  the  case  of  a  pregnant  woman  who 
suffered  from  a  fright  and  gave  birth  to  a  child  affected  with  a  "  feeble  " 
tremor.  Most  (Encyclopozdia  de  med.  Praxis,  Paris,  1836,  ii.  555)  refers 
in  a  few  words  to  several  cases  of  tremor  which  all  occurred  in  one 
family.  Sanders  (Reynolds's  System,  i.  p.  724)  reports  a  case  of  paralysis 
agitans  non-senilis  beginning  at  the  twelfth  and  lasting  till  the  sixty-sixth 
year.  Trousseau  says  that  senile  tremor  is  not  confined  to  the  aged,  but 
may  affect  persons  of  middle  age  or  even  adolescents.  Weschede 
(Virch.  Archiv,  Bd.  1.  Heft  2)  reports  a  case  of  supposed  paralysis  agitans 
occurring  in  a  boy  caused  by  the  kick  of  a  horse.  Post-mortem  showed, 
however,  that  this  was  a  case  of  disseminated  sclerosis.  And  the  state- 
ments of  Duchenne  (Ziemssen's  '  Cyclop.,  xiv.  p.  396)  and  other  early 
observers  that  paralysis  agitans  occurs  sometimes  in  early  life  are  based 
possibly  on  observations  of  cases  like  Meschede's.  Hennis  Green,  Go  wry, 
and  Sanders  speak  of  temporary  tremors  occurring  in  childhood. 
Wharton  Sinkler,  in  Pepper's  System  of  Medicine,  vol.  v.,  art.  "  Tremor/' 
speaks  of  a  patient  who  had  suffered  from  tremor  all  her  life.  Since 
finishing  this  article  my  attention  has  been  called  to  a  case  of  "  con- 
genital tremor,"  reported  by  Dr.  Predazzi,  of  Geneva  (Gazetta  degli  Os- 
pitali,  June  26,  1887).  The  patient  had  suffered  from  birth  from  an 
oscillatory  tremor  of  the  head  and  eyeballs. 

The  above  forms  all  that  I  can  find  bearing  on  the  affection  I  am 
about  to  describe  and  it  is  evident  that  no  one  has  more  than  incidentally, 
if  at  all,  observed  and  reported  such  cases  as  my  own.  Most,  Axenfeld, 
and  Sinkler  have  evidently  seen  examples  of  the  neurosis  I  am  de- 
scribing. 

Clinical  Cases. — I  have  seen  and  studied  the  tremor  in  three  families, 
and  in  all  it  preserves  a  general  clinical  resemblance.  In  one  family  I 
have  obtained  by  far  the  most  complete  and  striking  records,  and  I  can 
best  serve  my  purpose  by  first  giving  an  account  of  the  disease  as  it 
occurred  in  one  of  its  members. 

Family  A.  Case  I. — K  R.,  aged  seventy-seven,  w.  U.  S.  The  family 
history  will  be  referred  to  later.  The  patient  is  a  man  of  medium  weight, 
spare  build,  and  of  nervous,  excitable  temperament.  He  is  a  much  more 
than  ordinarily  intelligent  man,  taking  an  active  interest  in  religious 


388 


DANA,  HEREDITARY  TREMOR. 


political,  and  local  affairs.  In  early  life  he  took  a  degree  in  medicine, 
but  never  practised.  His  habits  have  been  good.  He  has  never  used 
alcohol  or  tobacco.  He  has  had  no  fits  or  other  nervous  disease,  but  has 
had  pneumonia  five  times.  He  has  had  the  tremor  from  early  childhood, 
it  has  continued  about  the  same  for  over  seventy  years.  It  affects  his 
arms  most,  but  also  his  lower  limbs.  Any  noise  or  excitement  increases 
it,  and  enlarges  its  range.  He  has  no  nystagmus,  and  his  eye-sight 
is  good.  The  tremor  affects  the  two  sides  about  equally.  It  is  fine  in 
character,  like  a  neurasthenic  tremor,  and  there  is  not  that  wide  range 
in  the  movement  characteristic  of  old  cases  of  paralysis  agitans.  It 
is  accompanied  with  a'slight  contracture  of  the  fingers,  but  otherwise 
there  is  no  motor  disturbance,  such  as  rigidity,  cramp,  or  paresis.  The 
tremor  can  be  voluntarily  controlled  for  a  short  time,  so  that  the  patient 
has  been  able  all  his  life  to  pursue  his  trade  of  watch-making,  and  he 
acquired  justly  the  reputation  of  being  the  best  workman  in  his  section 
of  the  country.  I  have  myself  seen  him  pick  up  a  piece  of  the  delicate 
machinery  of  a  watch  in  his  forceps,  carry  it  to  the  place  where  it  should 
be  fitted,  the  hand  trembling  like  an  aspen  until  just  before  it  reached  its 
destination,  when  it  suddenly  became  firm  and  steady  and  deposited  its 
burden  just  in  the  right  place.  The  tremor  does  not  increase,  nor  does 
it  cease  when  a  voluntary  movement  is  made  as  shown  above ;  it  is  only 
by  a  distinct  and  special  effort  of  the  will  that  momentary  control  is 
obtained.  It  is  slightly  apparent  in  the  handwriting,  though  this  is 
now  as  steady  as  that  of  most  men  who  are  seventy-seven  years  old.  He 
controls  the  tremor  better  and  writes  more  smoothly  with  a  lead-pencil. 

When  excited  the  tremor  affects  his  head,  which  oscillates,  and  also 
his  muscles  of  articulation,  so  that  speech  is  indistinct,  while  all  the  ex- 
tremity muscles  are  affected  in  a  greatly  exaggerated  way,  thus  increas- 
ing greatly  his  apparent  mental  excitement.  The  tremor  ceases  during 
sleep. 

Close  examination  shows  his  muscular  system  to  be  normally  devel- 
oped and  strong.  The  patella  tendon  reflex  is  normal,  not  absolutely 
exaggerated  at  least,  though  considering  his  age  it  may  be  relatively  so. 
His  gait  and  posture  are  natural,  nor  does  he  in  any  way  show  evidence 
of  natural  malformation,  or  progressive  nervous  disease.  He  can  even 
now  do  work  upon  a  watch. 

This  patient  presents  in  its  most  marked  form  the  tremor  which  runs 
through  the  family.    The  history  of  this  is  most  interesting. 

I.  The  grandfather  was  greatly  addicted  to  alcohol  and  tobacco.  He 
had  no  tremor. 

II.  The  father  was  a  man  of  very  nervous  temperament,  quick  in 
movement,  violent  in  temper.  He  used  no  alcohol  or  tobacco.  Had  no 
tremor,  but  became  insane  early  in  life  and  died  at  the  age  of  fifty-five. 

His  wife  was  a  strong,  healthy  woman,  without  tremor. 

III.  The  patient,  whose  history  has  been  given,  was  one  of  nine  chil- 
dren, six  sons  and  three  daughters,  all  of  whom  had  the  tremor  and  a 
slight  flexion  of  the  fingers. 

Of  the  nine,  (1)  the  oldest  child,  a  daughter,  had  nine  children,  four 
sons  and  five  daughters,  one  son  became  insane.  All  the  children  had 
the  tremor  more  or  less,  especially  when  excited. 


DANA,  HEREDITARY  TREMOR. 


3S9 


(2)  The  second  child,  a  boy,  became  insane  at  twenty-one,  but  lived 
till  eighty.    He  had  the  tremor. 

(3)  The  third  child,  a  daughter,  married  a  man  who  became  insane. 
She  had  a  son  and  two  daughters,  the  son  became  insane  probably.  The 
daughters  were  healthy.    All  had  the  tremor. 

(4)  The  fourth  child,  a  son,  had  five  children,  who  all  had  the 
tremor. 

(5)  The  fifth  child  was  the  patient  whose  history  is  given.  He  was 
married  twice,  and  had  two  children  by  the  first,  and  one  by  the  second 
wife.  These  children  were  unusually  intelligent,  and  even  talented. 
All  had  the  tremor  in  a  slight  degree. 

(6)  The  sixth  child  was  a  son  still  living  and  reported  "  very  pecu- 
liar." He  married  a  woman  who  became  insane,  and  had  five  children. 
One  was  an  inebriate.    All  had  the  tremor. 

(7)  The  seventh  son  was  intemperate,  was  twice  married,  and  had 
nine  children,  all  having  the  tremor.  One  of  the  children,  a  daughter, 
had  epilepsy.  She  herself  has  had  four  children,  one  of  these  had  de- 
cided tremor.  The  three  oldest  had  epilepsy,  two  dying  in  eclamptic 
attacks. 

(8)  The  eighth  child,  a  daughter,  is  still  living,  she  has  never  married. 
She  was  always  peculiar,  and  has  the  tremor  markedly. 

(9)  The  ninth  child,  a  son,  died  childless.    He  had  no  tremor. 
Summary  of  History  of  Family  A.  —  Grandfather  very  intem- 
perate, but  never  insane. 

Father  insane,  but  not  intemperate.  He  had  nine  children.  They 
all  had  the  tremor. 

One  son  insane  from  early  life. 

One,  a  lover  of  strong  drink,  but  not  a  confirmed  inebriate. 

Two  were  very  peculiar,  and  would  be  called  now-a-days  "  cranky." 

Two  died  without  marrying. 

All  grew  to  adult  life  and  most  of  them  lived  to  advanced  old  age. 
Several  showed  intelligence  and  mental  activity  much  above  the  aver- 
age. 

These  nine,  or  rather  seven  of  them,  produced  thirty-four  children ; 
and  all  of  these  that  lived  to  grow  up  showed  the  family  tremor, 
through  in  varying  degrees.  In  two  branches  insanity  appeared,  in  one 
a  member  was  intemperate,  and  in  one  branch  epilepsy  developed  in  the 
daughter  and  grandchildren.  The  tremor  also  appeared  in  one  of 
these  latter.  I  cannot  learn  whether  it  has  developed  in  other  branches 
among  the  grandchildren,  but,  if  so,  it  is  much  less  marked,  and  the 
opinion  in  the  family  is  that  the  tremor  is  dying  out.  The  total  number 
of  cases  in  the  family  is  forty-five. 

In  none  of  these  cases  did  the  tremor  increase  upon  them  as  they 
grew  older.    It  is  a  curious  coincidence  that  the  family  early  embraced 


390 


DANA,  HEREDITARY  TREMOR. 


spiritualism,  and  that  that  has  passed  through  the  different  generations 
along  with  the  tremor. 

Genealogical  Table  Showing  the  Development  of  the 
Hereditary  Tremor  in  Family  A. 


Generation  I. 


Grandfather, 
intemperate, 
and  a  tobac- 
co user. 
No  tremor. 


Aunt, 
insane. 


Father, 
temperate, 


no  tremor. 


Aunt. 


1st  child,  da 
ter,  tremor. 
Married. 


IV. 

1st,  son,  insane,  tremor. 
2d,    "  tremor. 
3d,  " 
4th,  " 

5th,  daughter,  tremor. 
6th, 

7th,  " 
8th,  " 
9th, 


2d  child,  son,  in-  "1 
sane  at  20  ;  died  [ 
at  80  ;  tremor.  j 
Single. 

3d  child,  daughter, 
tremor, 
Married. 


4th  child,  son. 
tremor, 
Married. 


1st,  son,  insane  ?  tremor. 
2d,  daughter,  " 

3d,         "  jj  % 

f  1st,  son,  tremor.  See  hist. 
|  2d,  " 

-j  3d,  daughter,  tremor. 
4th, 
5th, 


5th  child,  son  (see     f  1st,  son,  tremor. 
history),  tremor.    <  2d,    "  " 
Married.  (3d,  " 


6th  child,  son ; 
very  peculiar  ; 
tremor  Married. 


7th  child,  son ; 
intemperate. 
Married. 


f  1st,  son,  intemp.  tremor. 

i  2d,    "  tremor. 

1  3d,    «  » 

|  4th,  " 

L  5th,  " 

1st,  son,  tremor. 
2d,  " 
3d,  " 

4th,  daughter,  tremor  and  f  1,  epilepsy,  tremor. 
epilepsy.  j  2,  " 

j  5th,  daughter,     "  j  3,  " 

6th,       "  "  I  4,  1  year  old. 

7th, 
j  8th, 
L  9th, 


8th  child,  daugh 
ter,  "peculiar 
tremor.  Singl 

9th  child,  son, 
tremor.  Single. 


Case  II. — Through  the  kindness  of  Dr.  Couland,  of  Brattleboro,  Vt., 
I  am  able  to  give  an  account  of  the  tremor  occurring  in  its  second 
generation. 

The  person  examined  is  also  a  watchmaker  and  jeweller,  and  an  ex- 
cellent one.  He  is  about  forty  years  of  age  and  married.  His  health 
has  been  good,  his  habits  temperate,  and  he  has  never  had  any  other 
nervous  disorder  than  the  one  to  be  described.  He  is  a  man  of  nervous 
temperament,  but  quiet  in  manner  and  habits. 

His  tremor  began  in  early  childhood,  and  no  cause  other  than  heredity 
is  assigned.  It  is  bilateral  and  affects  his  arms  chiefly.  Occasionally 
there  is  tremor  of  the  orbicularis  on  the  right  side  (perhaps  from  wear- 


DANA,  HEREDITARY  TREMOR. 


391 


ing  his  jeweller's  glass  *?).  He  lias  also  nystagmus,  but  never  tremor  of 
tongue,  or  lips,  or  neck  muscles.  The  tremor  has  not,  he  says,  pro- 
gressed, and  he  says  that  it  does  not  interfere  with  his  work,  though  Dr. 
Couland  seems  to  think  that  occasionally  it  does.  It  probably  is  annoy- 
ing because  it  requires  an  extra  effort  to  steady  the  hand.  The  patella 
tendon-reflex  is  decidedly  exaggerated. 

He  does  not  suffer  from  rigidity,  cramps,  or  neuralgia.  I  have  long 
personally  known  the  patient  in  previous  years,  and  have  seen  him  at 
his  work.    His  tremor  is  fine,  like  that  of  the  preceding  generation. 

We  may  possibly  have  a  developing  organic  trouble  in  this  case,  but 
the  family  history  is  against  it. 

I  have  fortunately  been  able  to  secure  evidence  sufficient  to  show  that 
hereditary  tremor  is  not  a  freak  confined  to  the  family  just  described. 

I  have  the  records  of  a  second  family  in  which  there  were  three  cases, 
and  of  a  third  family  in  which  there  were  two.  Two  of  the  cases  in  the 
second  family  I  have  seen,  and,  indeed,  have  personally  known  for  a 
long  time. 

Family  B. — In  this  family  the  tremor  is  found  in  only  three  persons, 
an  uncle  and  two  nephews,  on  the  maternal  side.  The  parents  are  both 
healthy,  and  have  been  temperate  and  regular  in  their  habits. 

The  children  consisted  of  three  sons  and  a  daughter.  One  son  was  a 
person  of  irregular  habits,  and  died  in  early  manbood.  He  had  no 
tremor.  The  other  two  have  had  the  tremor  from  childhood,  but  no 
other  nervous  disturbance.  The  one  who  suffered  from  the  tremor  most 
had,  however,  indulged  a  good  deal  in  tobacco  and  alcohol.  The  details 
of  his  case  were  as  follows : 

Case  I. — He  is  a  man  of  about  thirty-five  years  of  age,  of  strong  phys- 
ique, a  carpenter  by  trade.  He  is  of  nervous  temperament,  quick,  and 
intelligent.  Has  had  no  fits  or  nervous  disorder  other  than  the  tremor. 
This  began  in  infancy,  and  has  been  somewhat  worse  than  it  is  at  present. 
This,  doubtless,  was  when  he  had  been  dissipating.  It  does  not  interfere 
with  his  work  as  a  carpenter,  but  at  times  it  is  not  perfectly  under  con- 
trol, and  has  interfered  with  his  writing  and  eating.  It  affects  his  arms 
mainly,  is  very  fine  in  character,  and  constantly  present.  He  has  no 
nystagmus  or  speech  disturbance.  His  deep  reflexes  are  a  little  exag- 
gerated. It  is  a  tremor  that  does  not  increase  or  cease  on  voluntary 
motion,  and  is  under  brief  control  of  the  will. 

Case  II. — The  brother  is  a  man  of  over  forty  years  of  age,  of  large, 
powerful  build,  and  robust  health.  He  is  a  business  man  of  unusual 
ability,  and  a  man  of  amiable  disposition  and  excellent  moral  character, 
and  temperate  habits.  He  has  always  had  good  health  and  suffered 
from  no  intercurrent  nervous  disorder.  His  tremor  began  in  early 
childhood,  without  known  cause.  It  is  much  slighter  in  amount  than 
in  the  brother,  and  he  hardly  notices  it  except  that  in  writing  sometimes 
he  has  to  steady  his  hand  by  voluntary  effort ;  yet  he  can,  as  a  rule, 
write  a  perfectly  smooth  hand.  Whatever  makes  him  nervous  increases 
the  tremor.  It  has  now  lasted  over  thirty  years  without  any  increase. 
He  has  several  healthy  children,  who  have  no  tremors.   There  is  no  ays- 


392 


DANA,  HEREDITARY  TREMOR. 


tagmus,  and  the  knee-jerk  is  normal.  The  tremor  resembles  his  brother's 
in  fineness,  and  in  its  affecting  the  upper  extremities  chiefly.  It  ceases 
during  sleep. 

Family  C. — Of  this  family  I  have  been  able  to  get  very  few  details, 
and  there  is  some  doubt  as  to  the  hereditary  character  of  the  tremor. 

Case  I. — James  M.,  aged  fifty-five.  He  came  to  my  clinic  at  the  Post- 
graduate School  suffering  from  a  tremor  which  presented  the  general 
characters  of  that  of  paralysis  agitans.  He  said  that  he  had  always 
had  the  tremor  since  he  was  a  boy,  it  had  always  been  more  severe  on 
the  right  side.    The  head  and  eyes  were  not  affected. 

The  patient  stated  that  his  uncle  had  been  affected  in  the  same  way, 
but  still  more  severely.    In  the  uncle's  case  the  head  was  affected. 

The  General  Features  of  Hereditary  Tremor. 

The  tremor  in  all  the  foregoing  cases  bears  a  general  clinical  resem- 
blance. It  begins  in  infancy  or  childhood,  sometimes  being  brought  out 
by  an  infectious  fever.  It  continues  without  progressing  in  severity 
during  a  lifetime,  which  it  does  not  shorten.  The  family  history  will 
reveal  neuroses  or  psychoses.  The  upper  extremities  are  most  noticeably 
affected,  but  it  may  involve  the  head,  neck,  eye,  laryngeal,  or,  in  fine, 
any  of  the  voluntary  muscles.  It  ceases  during  sleep,  and  can  be  inhib- 
ited temporarily  by  the  will.  Everything  that  produces  excitement  or 
nervousness  increases  the  tremor.  It  may  be  barely  noticeable,  except 
under  some  excitement,  or  the  influence  of  alcohol  or  tobacco.  It  does 
not  interfere  with  delicate  coordination.  It  neither  stops  nor  increases 
on  ordinary  voluntary  movements ;  in  this  respect  differing  from  the 
tremors  of  paralysis  agitans,  or  multiple  sclerosis.  There  may  be  with 
it  slight  contractures  of  the  fingers,  also  developed  early  and  non-pro- 
gressive, but  there  are  none  of  the  forced  movements,  rigidity,  paresis, 
subjective  sensations,  or  vasomotor  disturbances  of  paralysis  agitans, 
while  the  head  and  neck  are  not  so  much  affected,  as  in  senile  tremor. 
The  tendon-reflexes  may  or  may  not  be  exaggerated. 

The  tremor  is  most  nearly  like  that  occurring  in  neurasthenic  states, 
or  from  poisons,  only  there  is  no  general  nerve  exhaustion,  and  no  mus- 
cular weakness. 

It  is  associated  with  other  neuroses  or  psychoses,  such  as  insanity, 
inebriety,  and  epilepsy,  and  also  with  examples  of  unusual  talent  or 
intellectual  vigor.  And  it  illustrates  the  fact  that  a  neuropathic  taint 
in  a  family  may  develop  as  a  disease,  or  as  some  brilliant  mental  endow- 
ment. The  tremor  has  a  tendency  in  successive  generations  to  die  out. 
It  may  be  directly  hereditary  or  only  of  a  family  type,  occurring  in 
uncle  and  nephew.  It  may  occur  in  one  generation  only  as  a  congenital 
neurasthenic  tremor.  It  is  entirely  distinct  from  paralysis  agitans,  in 
the  fact  of  its  heredity,  non-progressiveriess,  and  absence  of  any  other 
neuromotor  or  vasomotor  symptoms.    It  differs  symptom atologically  also 


FRASER,   DYSPNCEA   OF    ASTHMA    AND  BRONCHITIS.  393 
• 

from  senile  tremor,  which  latter  generally  affects  first  and  entirely  the 
head  and  neck. 

I  have  not  thought  it  worth  while  to  discuss  its  pathology.  It  is 
undoubtedly  neuropathic,  not  myopathic,  and  in  the  following  classifi- 
cation of  tremors  I  should  place  it  among  the  neurasthenic  : 

Classification  of  Chronic  Tremor. 


Organic 


A.  Due  to  inflammatory 
sclerotic, 

neoplastic,  or 


post-hemiplegic  tremor, 
tremor  in  spasmodic  tabes, 
tremor  in  multiple  sclerosis. 

tremor  from  tumors  in  brain 
or  cord. 


degenerative  changes  af-  f 

fecting  the  motor  tract  J  paralysis  agitans. 

from  cortex  to  anterior  j  senile  tremor, 

cornu,  [ 


B.  Due  to  same  changes 
affecting  motor  nerves 
or  muscles, 


neuritic  tremor. 

fibrillary  myotrophic  tremor. 


Functional  -J 


Toxic  tremors. 


Neurasthenic  tremor, 


lead,  alcohol,  tea,  tobacco,  mer- 
cury, etc. 


f  (e.  9; 

j  acquired   -<  i 

(  professional. 
[_  hereditary  and  congenital. 


phthisical, 
syphilitic, 


THE  DYSPNOEA  OF  ASTHMA  AND  BRONCHITIS : 
its  causation,  and  the  influence  of  nitrites  upon  it.1 
By  Thomas  R.  Fraser,  M.D.,  F.R.S.,  F.R.C.P.E., 

PROFESSOR  OF  MATERIA  MEDICA  AND  OF  CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  EDINBURGH. 

Dyspnoea,  or  difficulty  in  breathing,  is  one  of  the  most  common  of 
symptoms  in  disease,  and  especially  in  disease  of  the  respiratory  apparatus, 
with  each  of  the  many  pathological  affections  of  which  it  may  be  asso- 
ciated. My  remarks,  however,  shall  be  restricted  to  its  manifestation  in 
asthma  and  bronchitis.  In  the  former  disease  it  presents  itself  as  an 
urgent  orthopnoeic  breathlessness,  and  in  the  latter  as  a  sensation  of  con- 
striction or  weight  in  the  chest,  and  a  difficulty  in  the  performance  of 
respiration.  The  breathlessness,  or  dyspnoea,  in  each  of  these  diseases 
is,  no  doubt,  dependent  on  defective  aeration  of  the  blood,  caused  either 
by  insufficient  contact  of  air  with  the  bloodvessels  in  the  pulmonary 
vesicles,  or  by  insufficient  movement  of  air  in  the  air-passages.  Insuffi- 
cient contact  occurs,  for  example,  when  the  air  vesicles  are  filled  with 
liquid  or  semiliquid  contents;  and  it  is  clearly  a  cause  that  is  to  some 
extent  productive  of  the  dyspnoea  of  bronchitis  in  many  of  its  forms 
and  stages,  as  well  as  of  the  dyspnoea  of  several  other  diseases  of  the 


1  Read  at  a  meeting  of  the  Medieo-Chirurgical  Society  of  Edinburgh,  on  the  6th  of  April,  1SS7. 


394     FEASEK,   DYSPNCEA   OF   ASTHMA   AND  BRONCHITIS. 

lungs.  Insufficient  movement  of  air  occurs  when  the  calibre  of  the  air- 
passages  is  reduced,  or  when  from  any  cause  the  expansion  or  retraction 
of  the  chest  is  impeded ;  and  this  imperfect  movement  of  air  is  usually 
recognized  as  a  cause  of  the  dyspnoea  that  occurs  in  both  asthma  and 
bronchitis. 

Asthma. 

The  symptoms  of  asthma  are,  indeed,  typically  those  that  are  to  be 
associated  with  imperfect  movement  of  air.  They  have  been  thus 
described  by  Riegel  :l 

"  The  patient  having  gone  to  bed  perfectly  well,  is  suddenly  awakened  in 
the  night,  while  sleeping  quietly,  by  an  intense  sense  of  oppression  and 
anxiety.  Breathing  is  very  laborious,  and  the  respiration  is  attended  with 
audible  whistling  and  rattling,  and  the  dyspnoea  rapidly  increases  to  an  exces- 
sive degree.  The  cyanosis  increases  from  minute  to  minute,  the  face  becomes 
bluish-red  and  turgid,  the  eyeballs  protrude,  the  patient  supports  himself  on 
both  arms  to  struggle  powerfully  for  air,  and  the  face  becomes  bathed  in  per- 
spiration. The  patient  can  no  longer  get  his  breath  in  the  recumbent  position, 
and  often  assumes  the  most  varied  attitudes  in  order  to  appease  in  a  measure 
his  craving  for  air.  .  .  .  Soon  the  patient  hurries  to  the  window  to  struggle 
for  a  mouthful  of  fresh  air.  In  spite  of  all  this,  he  does  not  appease  his 
craving  for  air,  even  by  the  forcible  action  of  all  his  auxiliary  muscles. 
The  paroxysm  continues  at  its  height  for  a  long  time — one,  two,  or  more 
hours — and  then  it  gradually  subsides.  The  respiration  becomes  easier  again, 
the  cyanosis  disappears,  the  patient  gradually  feels  freer  and  freer,  and  then 
drops  off  into  a  quiet,  deep,  uninterrupted  sleep." 

Now,  what  is  the  cause  of  this  intense  and  distressing  dyspnoea  ?  No 
anatomical  lesions  are  found  which  are  sufficient  to  account  for  it.  It  is 
regarded  as  a  functional  disorder  produced  by  alterations  in  normal 
physiological  conditions,  or  by  temporary  structural  changes  which 
disappear  wuth  the  asthmatic  paroxysm. 

Speculation  has  been  active,  however,  in  advancing  hypotheses  regard- 
ing the  nature  of  the  functional  or  temporary  structural  disturbances 
which  so  obviously  produce  an  obstruction  to  the  movement  of  air  along 
the  respiratory  passages.  Setting  aside  the  theories  that  were  originated 
previously  to  the  discoveries  of  Lsennec  and  Auenbrugger  in  physical 
diagnosis,  when  asthma  was  a  term  applied  not  only  to  pulmonary  dysp- 
noea, but  also  to  the  dyspnoea  of  diseases  of  the  heart  and  larger  blood- 
vessels, of  the  pleura,  glottis,  stomach,  and  other  organs  and  parts  of  the 
body  remote  from  the  lungs,  it  is  probable  that  the  first  certain  and  firm 
basis  of  knowledge  as  to  its  causation  was  supplied  by  the  demonstration 
by  Reisseissen,2  Prochaska,  and  Kolliker,  of  the  existence  of  a  muscular 
structure  in  the  bionchi.  The  demonstration  of  the  contractile  power 
of  this  muscular  structure,  by  Williams3  and  Longet,4  amply  confirmed 

1  Ziemssen's  Cyclopedia  of  the  Practice  of  Medicine,  1877,  vol.  iv.  p.  557. 

2  Ueber  den  Bau  der  Lungen.    Berlin,  1822 

Transactions  of  the  British  Association  for  the  Advancement  of  Science,  1840,  p.  411. 
4  Comptes  Bendus  des  Sciences,  1842,  t.  xv.  p  500. 


FRASER,  DYSPNCEA   OF   ASTHMA   AND   BRONCHITIS.  395 

by  the  subsequent  experiments  of  Paul  Bert1  and  others,  led  to  a  revival 
of  the  old  and,  for  a  time,  discredited  view,  that  asthma  is  produced  by 
a  spasmodic  affection  of  the  muscles  and  nerves  of  respiration.  The 
asthma  convulsivum  of  Willis  then  became  the  asthma  of  bronchial 
spasm  of  Cullen,  Romberg,  Bergsen,  Trousseau,  and  Salter ;  and  for 
more  than  half  a  century  was  the  generally  accepted  doctrine,  notwith- 
standing the  enunciation  of  other  theories,  usually  of  a  purely  specula- 
tive character,  such  as  those  of  Todd,  Bree,  Budd,  Walshe,  and  others. 

The  most  formidable  attacks  made  on  the  theory  of  bronchial  spasm, 
however,  were  probably  those  of  Wintrich,  in  1854,  and  of  Weber,  in 
1872 ;  as  the  important  hypothesis  of  Ley  den,2  that  the  asthmatic 
paroxysm  is  produced  by  irritation  of  the  vagus  terminations  in  the 
bronchi,  by  minute  sharp-pointed  crystals,  involves  as  an  explanation  of 
the  paroxysm  a  reflex  spasm  of  the  bronchial  muscles. 

Wintrich3  denied  that  spasmodic  contraction  of  the  bronchi  is  possible, 
and  maintained  that  the  only  explanation  consistent  with  the  phenomena, 
is  to  be  found  in  tonic  spasm  of  the  diaphragm  alone,  or  of  the  dia- 
phragm and  muscles  of  respiration  together.  He  was  led  to  adopt  this 
theory  from  the  results  of  some  experiments  which  appeared  to  show  that 
the  bronchi  did  not  contract  under  stimulation,  and  from  a  belief  that 
the  enlargement  and  hyper-resonance  of  the  lungs,  which  nearly  all 
observers  had  recognized  during  the  paroxysm  of  asthma,  could  not  be 
explained  by  spasm  of  the  bronchial  muscles.  His  opinions  were  sup- 
ported by  Bamberger,4  who  further  pointed  out  that  in  a  few  cases  of 
asthma  the  lower  limit  of  hepatic  dulness  remains  unchanged  during 
both  expiration  and  inspiration,  at  the  line  of  deep  inspiration.  Wint- 
rich's  opinions  and  statements  have  not  remained  unchallenged.  The 
most  damaging  criticisms  they  have  sustained  have  been  from  Biermer,5 
who  justly  occupies  the  position  of  being  one  of  the  ablest  supporters  of 
the  old  theory  that  asthma  is  caused  by  spasm  of  the  bronchial  muscles. 
Biermer  has  the  further  merit  of  having  prominently  shown  that  asthma 
is  characterized  by  expiratory  dyspnoea,  which  distinguishes  it  from  the 
dyspnoea  of  obstruction  in  the  larger  air-passages,  where  the  embarrass- 
ment is  more  decided  during  inspiration.  He  endeavors  to  prove  that 
spasm  of  the  bronchi  is  able  to  cause  enlargement  of  the  thorax,  increased 
percussion  resonance  over  the  lungs,  descent  and  restricted  movements  of 
the  diaphragm,  and  relative  difficulty  of  expiration  as  contrasted  with 

1  Lecons  sur  la  Physiologie  comparee  de  la  Respiration,  1870,  p.  379. 

2  Virchow's  Archiv,  1872,  Bd.  54,  p.  324 

3  Virchow's  Handbuch  der  speciellen  Pathologie  und  Therapie,  1854,  Bd  v  ;  and  Krankheiten  dor 
Respirationsorgane,  Erlangen,  1855-57. 

4  Wurzburger  medicinischc  Zeitschrift,  18C5,  Bd.  vi. 

5  TJeber  Bronchialasthma,  Sammluug  Klinischer  VortrSge,  1875,  12,  p.  30. 


396     FRASER,  DYSPNOEA  OF   ASTHMA  AND  BRONCHITIS. 


inspiration;  and  thus  he  apparently  succeeds  in  advancing  a  sufficient 
explanation  of  the  phenomena  of  asthma. 

The  other  most  formidable  opposition  which  the  doctrine  of  bronchial 
spasm  has  encountered,  may,  for  convenience,  be  associated  with  the 
name  of  Weber,  although  his  theory  seems  to  be  but  a  modification  of 
that  previously  advanced  by  Traube.  Weber1  ascribed  the  asthmatic 
attack  to  a  sudden  congestive  thickening  of  the  bronchial  mucous  mem- 
brane through  the  agency  of  vasomotor  nerves,  and  he  compared  the 
changes  that  were  thereby  produced  to  the  local  swelling  and  abnormal 
secretion  of  the  nasal  mucous  membrane,  which,  in  many  persons,  are 
produced  by  catarrh.  In  so  far  as  the  causation  of  the  asthmatic  dysp- 
noea is  concerned,  this  theory  also  agrees  with  the  old  supposition  that 
the  retrocession  of  certain  cutaneous  eruptions  is  productive  of  asthma,, 
revived  in  more  modern  times  by  Waldenburg,2  in  his  so-called  herpetic 
asthma,  and  also  by  Sir  Andrew  Clark,3  in  a  paper  published  last  year 
on  the  theory  of  bronchial  asthma. 

The  three  explanations  of  the  production  of  the  asthmatic  paroxysm r 
which  seem  at  the  present  time  to  be  maintained  more  than  any  others, 
are,  therefore,  embodied  in  the  theory  of  bronchial  spasm,  in  the  theory 
of  spasm  of  the  diaphragm,  associated,  or  not  associated,  with  spasm  of 
the  other  ordinary  or  extraordinary  muscles  of  respiration,  and  in  the 
theory  of  constriction  of  the  bronchial  tubes  by  swellings  of  a  hyperaemic, 
herpetic,  or  urticaria-like  character. 

The  existence  of  these  contending  theories  is  a  sufficient  proof  of  the 
difficulties  that  are  encountered  in  explaining  the  dyspnoea  of  asthma. 
The  observation  of  symptoms,  the  assistance  that  has  been  derived  from 
advancements  in  the  physiology  of  the  respiratory  and  nervous  systems, 
and  the  great  increase  in  knowledge  of  the  pharmacology  of  the  sub- 
stances that  are  used  as  remedies,  do  not  appear  to  have  entirely  solved 
the  difficulties.  No  doubt  the  second  theory,  that  of  Wintrich,  has  sus- 
tained from  Biermer  a  more  damaging  criticism  than  either  of  the  two 
others  has  yet  met  with  ;  and  it  may  be  regarded  as  demonstrated  that 
spasm  of  the  diaphragm,  combined  or  not  combined  with  spasm  of  the 
muscles  of  respiration,  is  not  the  essential  or  primary  cause  of  the  symp- 
toms of  asthma,  however  such  spasm,  in  some  cases  and  in  some  de- 
grees, may  occur  as  a  secondary  condition  during  the  paroxysm.  That 
able  and  trained  observers  are  divided  in  their  belief  as  to  the  correctness 
of  the  other  two  theories,  is  shown  by  the  statement  of  Dr.  Geddings,4  of 
America,  that  the  retrocession  of  cutaneous  eruptions  as  a  cause  of  asthma, 
has  of  late  years  "found  but  few  advocates  among  intelligent  physicians 

1  Ueber  Asthma  Nervosum  Tageblatt  des  45,  Versammlung  deutscher  Naturforscher  und  Aerzte  zu 
Leipsic,  1872,  p.  159. 

2  Berliner  klin.  Wochenschrift,  1873. 

3  The  American  Journal  of  the  Medical  Sciences,  January,  1886,  vol.  xci.  p  104 

4  Pepper's  System  of  Medicine,  1885,  vol.  iii.  p.  193. 


FRASER,   DYSPNCEA    OF    ASTHMA  AND  BRONCHITIS. 


397 


and  of  Riegel,1  that  the  severer  grades  of  asthma  "  can  be  explained  by 
the  mere  tumefaction  of  the  mucous  membrane,  seems  to  me  improb- 
able;" while  on  the  other  hand,  Sir  Andrew  Clark2  affirms  "that  the 
bronchial  spasm  theory  of  asthma  is  either  inadequate  to  explain  the 
phenomena  of  the  paroxysm,  or  is  not  in  harmony  with  the  present  state 
of  physiological  and  pathological  knowledge." 

It  seems  obvious  that  some  additional  facts  are  required  before  the 
truth  can  be  arrived  at.  The  obtaining  of  such  facts  is  desirable,  not 
merely  because  of  the  interest  that  is  attached  to  the  elucidation  of  the 
pathogenesis  of  this  as  of  all  diseases,  but  much  more  importantly,  on 
account  of  the  basis  that  would  thereby  be  gained  for  the  proper  appli- 
cation of  remedies.  A  very  different  treatment,  for  example,  would  be 
suggested  for  the  cure  of  a  dyspnoea  dependent  on  stenosis  of  the 
bronchial  tubes  caused  by  hyperemia,  from  the  treatment  of  a  dyspnoea 
dependent  on  stenosis  caused  by  spasm  of  the  bronchial  muscles. 

In  considering  the  problem  that  is  presented,  we  may  assume  that  ste- 
nosis of  the  bronchial  tubes  is  present.  It  is,  indeed,  impossible  to  over- 
look the  significance  of  what  are,  after  all,  the  most  constant,  as  well  as 
the  most  prominent,  of  the  physical  signs  that  accompany  the  asthmatic 
paroxysm.  On  auscultating  the  chest,  there  are  heard  rales  of  a  snor- 
ing, cooing,  and  whistling  character,  unaccompanied  during  a  part  of  the 
paroxysm,  in  most  cases,  by  any  moist  sounds,  and,  in  not  a  few  cases, 
heard  during  the  entire  paroxysm  unassociated  with  any  moist  sound,  and 
even  terminated,  as  Graves3  has  pointed  out,  without  any  expectoration 
whatever.  The  bronchi  in  which  these  sounds  occur  are  furnished  with 
bloodvessels,  which  might  dilate  and  produce  hyper?emic  swellings ;  they 
are  also  furnished  with  muscles,  which  might  contract  spasmodically 
and  here  and  there  produce  constrictions.  The  possibility  of  the  latter 
causation  of  constriction  cannot,  I  think,  admit  of  a  doubt,  since  the 
discoveries  of  the  earlier  investigators  have  been  so  amply  confirmed  by 
Paul  Bert,  and  by  Graham  Brown  and  Roy.4 

It  occurred  to  me  that  in  deciding  between  the  two  theories  of  the 
causation  of  the  asthmatic  paroxysm  which  seem,  at  present,  to  hold  the 
field,  some  assistance  might  be  derived  by  determining  if  the  auscultatory 
phenomena  to  which  I  have  referred  can  be  modified,  and  simultaneously 
the  dyspnoea  reduced  or  removed  by  the  action  of  any  pharmacological 
agent  that  markedly  influences  the  contractility  of  muscle,  and  espe- 
cially of  non-striped  muscle.  It  is  well  known  that  many  substances 
relieve  the  dyspnoea  of  asthma — such  substances,  for  example,  as  atro- 
pine, morphine,  and  chloral — but  their  influence  upon  the  auscultatory 
phenomena  has  not,  so  far  as  I  know,  been  investigated.    In  the  case 

1  Ziemssen's  Cyclopedia  of  the  Practice  of  Medicine,  1877,  vol.  iv.  p.  554.  -  Loc.  cit.,  p.  110. 

3  Clinical  Lectures  on  the  Practice  of  Medicine,  1864,  p.  507. 

4  The  Journal  of  Physiology,  vol  vi.,  1883  ;  appendix,  p.  xxi. 


398     FRASER,   DYSPNCEA   OF    ASTHMA   AND  BRONCHITIS. 

of  the  substances  I  have  mentioned  investigation  of  this  kind  is  not, 
indeed,  likely  to  afford  distinct  or  incisive  results,  as  their  influence  on 
the  dyspnoea  is  uncertain,  and,  usually,  but  slowly  produced,  and  as 
they  involve  in  their  sphere  of  action  many  parts  of  the  nervous  system ; 
while  it  has  not  been  proved  that  independently  of  this  involvement 
they  influence  the  contractility  of  non-striped  muscle  in  a  very  distinct 
or  powerful  manner. 

In  the  absence  of  evidence  of  the  existence  of  any  substance  that 
rapidly  and  distinctly  modifies  the  contractility  of  the  bronchial  tubes, 
the  analogy  in  structure  and  nerve  relationship  between  the  bloodvessels 
and  the  bronchial  tubes  suggested  that  the  most  appropriate  substances 
to  be  employed  for  the  purpose  I  have  stated  would  be  those  which  are 
capable  of  modifying  the  contractility  of  bloodvessels  by  direct  contact 
with  them.  Nitrite  of  amyl  has  been  shown  to  possess  this  action,  and 
the  probabilities  are  in  favor  of  its  being  possessed  also  by  other  nitrites 
and  by  substances  that  have  essentially  the  same  pharmacological  action. 

It  seemed  advisable  to  ascertain  positively,  in  the  first  place,  if  all  the 
chief  nitrites  possess  this  action,  and,  if  so,  to  what  extent  they  severally 
exert  it.  I  was  fortunate  in  inducing  Mr.  Sillar  to  undertake  a  series 
of  experiments  having  these  objects  in  view.  The  experiments  entailed 
a  large  amount  of  patient  observation,  and  they  were  made  with  great 
care  and  with  every  precaution  to  insure  accuracy.  The  mode  of  pro- 
cedure was  as  follows :  The  brain  and  spinal  cord  having  been  destroyed 
in  a  frog,  the  heart  of  the  animal  was  exposed  and  all  the  bloodvessels 
connected  with  it,  except  the  left  aorta  and  the  veins  opening  into  the 
sinus  venosuswere  ligatured.  A  canula  was  then  tied  into  the  left  aorta 
and  connected  with  a  tube  leading  to  reservoirs,  placed  always  at  the 
same  height  above  the  frog.  The  contents  of  any  one  of  the  reservoirs 
could  be  caused  to  flow  into  the  aorta  by  opening  or  shutting  clamps 
that  were  placed  on  the  tubes  leading  from  the  reservoirs.  The  rate  of 
flow  of  a  saline  solution  through  the  entire  vascular  system  of  the  animal 
was  first  ascertained,  and  then  a  solution  of  the  same  saline  containing  a 
given  quantity  of  a  nitrite  was  substituted  for  the  simple  saline  solution, 
and  its  rate  of  flow  through  the  bloodvessels  of  the  animal  was  ascer- 
tained. By  this  procedure  the  effects  of  contact  of  any  strength  of  a 
solution  of  nitrite  upon  the  bloodvessels  could  be  exactly  determined ; 
for  if  the  rate  of  flow  were  diminished,  it  would  be  shown  that  the  blood- 
vessels had  been  caused  to  contract,  whereas,  if  the  rate  of  flow  were  in- 
creased, it  would  be  shown  that  the  bloodvessels  had  been  caused  to  dilate. 
The  nitrites  that  were  tested  were  nitrite  of  amyl,  nitrite  of  ethyl,  and 
nitrite  of  sodium.  Without  entering  into  details,  I  will  content  myself 
with  stating  that  the  general  result  was  that  each  of  these  nitrites  pro- 
duced by  contact  a  decided  dilatation  of  the  bloodvessels,  in  a  few  in- 
stances so  great  that  the  passage  through  them  of  the  solution  was 


FRASEK,  DYSPNCEA  OF   ASTHMA    AND    BRONCHITIS.  399 

doubled  in  its  rate ;  and  that  dilatation  occurred,  usually,  in  less  than  a 
minute  after  the  nitrite  had  entered  the  bloodvessels,  and  was  continued 
for  periods  varying  from  thirty  to  ninety  minutes.  Nitrite  of  sodium  was 
found  to  be  the  least  powerful,  and  nitrite  of  amyl  the  most  powerful 
dilator  of  bloodvessels,  nitrite  of  ethyl  occupying  an  intermediate  posi- 
tion. The  difference  is  indicated  by  the  statement  that  whereas  a  solu- 
tion of  1  in  100,000  of  nitrite  of  amyl  was  sufficient  to  cause  a  marked 
increase  in  the  rate  of  flow  through  the  bloodvessels — indicating  a  dis- 
tinct dilatation  of  their  walls — it  was  necessary  to  employ  a  solution  of 
1  in  10,000  of  nitrite  of  sodium  to  produce  a  nearly  equal  effect. 

The  action  of  nitroglycerine  was  not  examined  in  the  same  manner,  as 
the  conditions  probably  required  to  effect  its  conversion  into  a  nitrite, 
which  exist  in  the  blood  of  a  warm-blood  animal,  could  not  be  obtained 
in  the  saline  solutions  substituted  for  the  blood  in  these  experiments.1 

A  few  experiments  were,  however,  also  made  with  alcohol  and  chloro- 
form. Somewhat  concentrated  solutions  of  the  former  produced  dilata- 
tion ;  but  no  constant  results  were  obtained  with  chloroform,  the  evidence, 
on  the  whole,  pointing  to  an  absence  of  any  dilatation  under  the  contact 
of  this  substance  with  the  bloodvessels. 

It  was  thus  shown  that  very  dilute  solutions  of  nitrites,  apart  altogether 
from  any  influence  they  may  exert  on  structures  at  a  distance,  produce 
dilatation  of  the  walls  of  bloodvessels  as  a  result  of  contact  with  them.  If 
they  could  be  shown  likewise  to  modify  in  asthma  the  condition  of  the 
bronchial  tubes,  whose  anatomical  relationships  to  bloodvessels  are  so 
marked,  it  is  obvious  that  an  important  step  would  be  gained  in  deciding 
which  of  the  theories  of  the  causation  of  the  asthmatic  paroxysm  is  the 
correct  one.  In  the  absence  of  any  direct  experimental  method  for  ascer- 
taining the  state  of  the  bronchi,  and  especially  for  estimating  the  changes 
that  might  be  produced  in  them  by  medicinal  agents,  during  an  asthmatic 
paroxysm,  it  seemed  to  me  that  the  observation  of  the  auscultatory  phe- 
nomena, which  have,  by  nearly  universal  consent,  been  explained  by 
^     stenosis  of  the  bronchi,  would  be  likely  to  supply  important  evidence. 

My  first  observation  was  made  in  1880,  on  a  patient,  Jessie  L.,  twenty- 
two  years  of  age,  suffering  from  asthma  and  from  excitement  of  the  cir- 
culation and  slight  enlargement  of  the  thyroid  gland.  She  was  one  of 
three  sisters  who  presented,  in  various  forms,  the  symptoms  of  exophthal- 
mic goitre.  The  dyspnoea  had  lasted  for  several  weeks ;  it  was  most 
severe  at  night,  but  occasionally  manifested  itself  during  the  day.  When 
the  observation  was  made  (August  14,  1880)  she  was  sitting  up  in  bed 
suffering  from  great  breathlessness.    The  pulse  was  100  and  the  respira- 

1  Since  this  sentence  was  written,  Dr.  Atkinson,  in  the  course  of  an  elaborate  research  on  nitrite.*, 
made  in  my  laboratory,  has  found,  in  experiments  similar  to  those  above  described,  that  nitroglycerine 
in  very  dilute  solutions  powerfully  dilates  the  arteries  and  capillaries.  This  local  action  of  nitrites  ha* 
also  been  l-ecently  shown  to  occur  in  warm-blooded  animals  hy  K.  Robert  (Ueber  die  Heeintlussung  dor 
peripheren  Gefiisse  durch  pharmakologischo  Agcnten.  Arcbiv  fiir  experimentale  Pathologic  and 
Pharmakologie,  Bd.  22,  188G,  p.  77). 


400     FRASEK,  DYSPNOEA   OF    ASTHMA   AND  BRONCHITIS. 

tions  28  per  minute.  On  auscultating  the  front  of  the  chest,  it  was  found 
that  expiration  was  markedly  prolonged,  and  that  both  inspiration  and 
expiration  were  accompanied  with  cooing,  whistling,  and  creaking  rales, 
and  with  occasional  medium  crepitations. 

At  1  55'  p.m.  she  began  to  inhale  10  minims  of  nitrite  of  amyl  placed  on 
blotting-paper  at  the  bottom  of  a  small  glass  tumbler,  and  she  continued 
inhaling  for  about  one  minute  and  fifty  seconds,  the  chest  being  contin- 
uously auscultated  during  the  observations. 

At  1  56'  30",  the  face  was  flushed,  and  the  pulse  was  120  per  minute. 

At  1  57',  the  cooing,  whistling,  and  creaking  rales  had  entirely  disap- 
peared, and  the  patient  spontaneously  remarked  that  her  breathing  was 
easier,  and  that  the  sensation  of  tightness  had  disappeared  from  the 
chest. 

At  1  58',  the  rales  had  returned,  but  as  yet  to  only  a  slight  extent;  the 
breathing  had  become  more  difficult,  and  the  pulse  was  96  per  minute. 

At  2  4',  the  pulse  was  96,  and  the  respirations  28  per  minute,  while 
the  breathing  was  as  difficult,  and  the  rales  as  loud  and  continuous  as 
they  had  been  before  the  iuhalation. 

From  2  6'  to  2  7'  she  again  inhaled  nitrite  of  amyl. 

At  2  6'  30",  the  face  was  flushed. 

At  2  6'  45",  the  flushing  had  increased,  the  rales  in  the  chest  had 
entirely  disappeared,  and  the  patient  stated  that  the  breathing  was  per- 
fectly easy. 

At  2  6'  50",  the  pulse  was  122,  and  the  respirations  30  per  minute, 
while  the  breath  sounds  were  still  unaccompanied  with  rales. 
At  2  9',  cooing  sounds  were  occasionally  heard. 

At  2  11',  the  cooing  sounds  continued,  but  the  breathing  was  still  easy. 

At  2  12',  the  breathing  was  embarrassed,  and  cooing,  creaking,  whist- 
ling, and  crepitant  rales  were  audible,  though  they  were  not  so  continuous 
as  immediately  before  the  second  inhalation. 

At  2  19',  the  pulse  was  95,  and  the  respirations  30,  while  the  ausculta- 
tory phenomena  and  the  difficulty  of  breathing  were  as  pronounced  as 
before  the  administration  of  nitrite  of  amyl. 

From  2  22'  to  2  23'  she,  a  third  time,  inhaled  nitrite  of  amyl. 

At  2  22'  30",  the  face  was  very  red. 

At  2  22'  50",  the  pulse  was  126,  and  the  respirations  23  per  minute, 
while  the  rales  had  entirely  disappeared,  and  the  breathing  was  again, 
in  her  own  words,  "  quite  easy." 

At  2  25',  the  pulse  was  90,  and  the  respirations  were  28  per  minute ; 
the  redness  of  the  face  had  completely  disappeared,  the  breathing  was 
slightly  embarrassed,  and  cooing  and  creaking  rales  were  occasionally 
heard. 

At  2  28',  the  breathing  was  as  much  embarrassed  as  it  originally  had 
been ;  and  with  the  return  of  dyspnoea  there  was  a  complete  return  of 
the  auscultatory  phenomena  that  had  been  present  before  the  first  inha- 
lation of  nitrite  of  amyl. 

There  had  been  no  cough  or  expectoration  from  the  commencement 
to  the  termination  of  the  observations.  The  patient  stated  that  the 
breathlessness  and  sense  of  tightness  in  the  chest  had  been  entirely 
removed  for  a  time  by  the  inhalations,  and  the  only  unpleasant  effect 
they  seem  to  have  produced  was  a  briefly  lasting  sense  of  fulness  in  the 
head. 

To  illustrate  more  clearly  the  relationship  between  the  effects  on  the 


FRASER,   DYSPNCEA   OF  ASTHMA 


AND  BRONCHITIS. 


401 


asthma  and  on  the  circulation,  I  would  refer  to  the  pulse-tracings  taken 
frequently  during  the  observations.  They  show,  in  a  very  remarkable 
manner,  a  coincidence  between  the  fall  of  blood  tension  and  the  cessa- 
tion of  the  dyspnoea  and  auscultatory  phenomena,  and  also  between  the 
return  to  the  original  state  of  the  blood  tension  and  the  reappearance  of 
the  dyspnoea  and  auscultatory  phenomena.  As  the  lowered  blood  tension 
is  accompanied  with  acceleration  of  the  heart's  contractions,  it  can  only 
be  accounted  for  by  the  dilatation  of  bloodvessels. 

Fig.  1. 


Before  first  inhalation.    Pulse  100,  respirations  28  per  minute.    Breathing  much  embarrassed, 

rales  abundant. 


Nitrite  of  Amyl  Inhaled  during  nearly  Two  Minutes. 
Fig.  2. 

Two  minutes  after  inhalation  commenced.    Pulse  120  per  minute.    Breathing  quite  easy.    Xo  rales. 


Fig.  3. 


Fig.  4. 


One  minute  after  inhalation  ceased.  Pulse 
96  per  minute.  Breathing  slightly  embar- 
rassed.   Rales  occasionally  heard. 


Seven  minutes  after  inhalation  ceased.  Pulse 
96,  respirations  28  per  minute.  Breathing  em- 
barrassed.   Rales  nearly  continuous. 


Second  Inhalation  of  Nitrite  of  Amyl  during  Two  Minutes,  begun 
Nine  Minutes  after  the  first  Inhalation  ceased. 


Fig.  5. 


Fig.  6. 


omuuuu 


Fifty  seconds  after  second  inhalation  com- 
menced. Pulse  122,  respirations  30  per 
minute.   Breathing  perfectly  easy.    No  rales. 


Two  minutes  thirty  seconds  after  second  in- 
halation ceased.  Pulse  96,  respirations  28  per 
minute.    Breathing  easy.    Occasional  rales. 


Fig.  7. 


Eight  minutes  after  second  inhalation  ceased. 
Pulse  96,  respirations  30  per  minute.  Breath- 
ing embarrassed.    Rales  more  frequent. 

NO.  CLXXXV1II  —  OCTOBER,  18S7. 


Fig. 


Twelve  minutes  after  second  inbalation 
ceased.  Pulse  95,  respirations  SO  per  minute. 
Breathing  embarrassed.    Rales  abundaut 


402     F RASE  R,  DYSPNOEA   OF   ASTHMA   AND  BRONCHITIS. 

Third  Inhalation  of  Nitrite  of  Amyl  during  One  Minute,  begun  Fifteen 
Minutes  Thirty  Seconds  after  Second  Inhalation  ceased. 


Fig.  9. 


Fig.  10. 


Fifty  seconds  after  third  inhalation  com- 
menced. Pulse  126,  respirations  23  per  minute. 
Breathing  quite  easy.    No  rales. 


Two  minutes  after  third  inhalation  ceased. 
Pulse  90,  respirations  28  per  minute.  Breath- 
ing easy.    Kales  only  rarely. 


Fig.  11. 

J^J\jVjHj\jVJV 

Eighteen  minutes  after  third  inhalation  ceased.    Pulse  8a,  respirations  28  per  minute. 
Breathing  much  embarrassed.    Rales  very  abundant. 

Several  observations  were  made  on  other  patients  suffering  from 
asthmatic  dyspnoea,  by  administering  nitrite  of  amyl  or  nitrite  of  ethyl 
by  inhalation.  The  results  generally  corresponded  very  closely  with 
those  described  in  the  above  observation. 

It  is  apparent  that,  although  the  effects  are  of  the  greatest  significance 
in  regard  to  one  of  the  main  objects  for  which  the  observations  had 
been  made,  they  w7ere,  at  the  same  time,  of  a  very  transient  duration. 
Before  any  further  observations  had  been  made  on  asthma,  I  had, 
however,  succeeded  in  collecting  a  number  of  facts  which  rendered 
it  probable  that  effects  of  a  more  lasting  description,  and  therefore  of' 
greater  value  to  therapeutics,  might  be  obtained  were  the  nitrites  admin- 
istered through  the  mouth.  The  observations  in  which  this  method 
of  administration  was  followed  derive  an  additional  importance  from 
the  circumstance  that  they  were  made  on  patients  during  extremely 
severe  dyspnoea,  of  a  markedly  orthopnoeic  character.  These  severe- 
attacks  occurred  only  during  the  night  or  the  early  hours  of  the  morning. 
The  occasions  of  their  occurrence  were  somewhat  irregular,  so  that  it 
could  not  be  anticipated  with  certainty  that  they  would  occur  on  any 
special  night.  It  was,  therefore,  necessary  to  entrust  the  observations 
to  those  who  could,  at  any  moment,  make  them.  They  were  kindly 
undertaken  by  Dr.  Vaughan,  who  was  at  the  time  acting  as  my  resident 
physician  at  the  Royal  Infirmary,  and  by  Mr.  Tofft,  a  clinical  clerk  in 
my  wards,  who  remained  in  the  hospital  during  several  nights  for  the 
purpose.  Both  gentlemen  had  previously  assisted  me  in  many  observa- 
tions of  this  kind,  and  they  were,  therefore,  thoroughly  qualified  to- 
undertake  the  work. 


FBASEB,  DYSPNOEA    OF   ASTHMA   AND  BRONCHITIS.  403 

Observation  I. — An  interesting  and  complete  series  of  observations 
was  made  on  a  man,  Hugh  G.,  forty  years  of  age,  who  had  suffered  from 
asthma  for  four  years,  and  had  been  an  inmate  of  the  Royal  Infirmary 
for  three  months.  As  one  generally  finds  in  cases  of  so  long  duration, 
emphysematous  changes  had  been  produced  in  the  lungs,  and  symptoms 
of  bronchitis  were  also  present.  The  emphysema  was,  however,  only 
moderate,  and  the  bronchitis  slight,  and  frequently,  for  days,  the  symp- 
toms of  the  latter  were  entirely  absent.  His  sputum  was  usually  tena- 
cious and  gelatinous,  and  small  in  quantity.  Several  times  in  each  week 
his  sleep  was  interrupted  by  severe  attacks  of  breathlessness,  which  lasted 
from  an  hour  and  a  half  to  three  hours,  and  sometimes  occurred  twice  or 
even  thrice  in  one  night.  During  the  attacks  the  patient  either  sits  up  in 
bed  or  walks  about  the  ward,  sitting  down  at  times  to  recover  strength. 
He  struggles  violently  for  breath,  inspiration  and  expiration  succeed 
each  other  rapidly  for  a  short  time,  then  expiration  becomes  brief,  the 
chest  seems  to  become  rigid  in  full  inspiration,  violent  respiratory  efforts 
are  made  with  but  little  change  in  the  volume  of  the  thorax,  and  the  ex- 
traordinary muscles  of  respiration  are  brought  into  play  with  but  little 
result.  After  this  state  has  lasted  for  some  time,  endeavors  are  made  to 
cough,  which  are  at  first  unsuccessful,  but  after  a  number  of  gasping  and 
strained  inspirations  and  expirations,  he  at  last  succeeds  in  coughing, 
and  bye  and  bye  a  small  quantity  of  frothy  and  tenacious  sputum  is  ex- 
pectorated, when  the  patient  either  at  once  or  soon  after  obtains  relief. 
During  the  greater  part  of  the  paroxysm,  the  face  and  neck,  and  to  a 
less  extent  the  chest,  are  much  congested. 

Observation  II. — On  the  30th  of  December,  1886,  a  paroxysm  began 
at  about  4  30'  a.  m.  When  the  patient  was  examined,  eight  minutes 
afterward,  he  was  sitting  up  in  bed  holding  his  sides,  and  so  breathless 
that  he  could  scarcely  speak.  The  veins  of  the  neck  were  turgid,  and 
the  labored  breathing  was  accompanied  with  loud  wheezing  audible  in 
the  corridor  of  the  ward  at  a  distance  of  at  least  forty  yards  from  the 
patient.  The  pulse  was  120  per  minute  and  feeble,  and  the  respirations 
were  36  per  minute. 

At  4  41',  both  sides  of  the  chest  were  auscultated,  with  the  result  that 
the  ordinary  breath  sounds  were  everywhere  supplanted,  during  both 
inspiration  and  expiration,  by  continuous  rhonchi  and  sibili.  The  time- 
relation  of  inspiration  to  expiration  was  1  :  H. 

At  4  43',  five  minims  of  nitrite  of  amyl  in  two  drachms  of  water  were 
given  to  the  patient. 

At  4  43'  30",  at  the  left  side  of  the  chest,  the  rhonchi  and  sibili  had 
markedly  diminished  ;  at  the  right  side  there  were  no  accompaniments 
whatever,  with  the  exception  of  a  few  medium  crepitations  at  the  end  of 
expiration.    The  face,  hands,  and  chest  were  distinctly  flushed. 

At  4  44',  the  pulse  was  96,  and  fuller,  and  the  respirations  were  24  per 
minute.    The  patient  said  that  his  breathing  was  greatly  relieved. 

At  4  45'  30",  the  breathing  at  the  right  side  was  absolutely  clear  and 
vesicular;  and  at  the  left  side  there  was  only  a  slight  sibilus  during 
inspiration,  expiration  being  free  from  accompaniments.  The  wheezing 
had  by  this  time  practically  disappeared. 

At  4  50',  the  time-relation  of  inspiration  to  expiration  was  1  '  to  2J. 

At  4  51',  there  were  no  accompaniments  whatever  at  any  part  of  the 
chest  either  duriug  inspiration  or  expiration,  except  a  few  medium  crepi- 
tations that  occurred  at  varying  intervals  and  at  both  sides. 


404     FRASER,  DYSPNCEA  OF    ASTHMA   AND  BRONCHITIS. 

At  4  53',  at  the  right  side,  the  breath  sounds  continued  clear,  except 
that  now  and  then  a  distant  rhonchus  was  heard  at  the  beginning  of 
expiration.;  at  the  left  side,  however,  there  were  sibili  throughout  ex- 
piration and  rhonchi  during  a  part  of  inspiration. 

At  4  55',  the  patient  stated  that  his  breathing  had  become  a  little 
more  difficult  than  it  had  been  a  short  time  before,  and  he  referred  the 
difficulty  to  the  upper  half  of  the  sternum. 

At  4  58',  the  pulse  was  90  and  the  respirations  were  22  per  minute, 
and  the  former  was  irregular  in  the  character  of  the  pulsations. 

At  5  a.  M.,  at  the  right  side,  thereVere  no  accompaniments  excepting 
medium  crepitations  ;  and  at  the  left  side  there  was  only  a  brief  sibilus, 
sometimes  with  inspiration  and  at  other  times  with  expiration. 

At  5  8',  the  patient  said  he  felt  perfectly  well. 

At  5  14',  at  the  right  side,  there  was  a  short  rhonchus  at  the  beginning 
of  expiration,  but  no  accompaniment  whatever  at  the  left  side.  The 
patient  was  now  lying  on  the  back  no  longer  propped  up.  He  seemed 
quite  frse  from  any  difficulty  in  breathing  and  he  wTas  apparently 
desirous  to  be  allowed  to  sleep. 

He  was  again  seen  at  6  10'  when  he  seemed  to  be,  and  expressed  him- 
self as  being,  free  from  dyspnoea,  but  on  auscultating  the  chest  a  few 
sibili  and  rhonchi  were  occasionally  heard. 

On  the  following  day  the  patient  was  very  well.  His  breathing  was 
unembarrassed,  but  he  experienced  a  little  palpitation,  and  he  said  he 
had  found  it  necessary  to  empty  his  bladder  more  frequently  than  he 
usually  did. 

Observation  III. — On  the  same  patient  the  following  observations 
were  made  with  nitrite  of  ethyl  (nitrous  ether). 

On  the  8th  of  January,  1887,  difficulty  of  breathing  began  to  be 
experienced  soon  after  2  a.  m. 

At  3  15'  a.  m.,  the  patient  was  propped  up  in  bed,  breathing  with  great 
difficulty  and  showing  signs  of  much  distress.  This  difficulty  was  felt 
both  in  the  act  of  inspiration  and  of  expiration,  but  it  was  rather  worse 
in  that  of  expiration,  or,  as  the  patient  described  it,  "  it  was  worse  to  get 
the  breath  out."  There  was  also  loud  wheezing.  A  small  quantity  of 
sputum  had  been  expectorated,  which  was  tenacious  and  of  a  yellowish 
color. 

At  3  20',  on  auscultation,  rhonchi  and  sibili  were  heard  during  inspi- 
ration and  expiration  over  both  sides  of  the  chest,  but  rather  louder  over 
the  right  than  the  left  side.  The  pulse  was  96  and  the  respirations  were 
22  per  minute.  The  relation  of  inspiration  to  expiration  was  f  :  H  on 
both  sides. 

At  3  26',  ten  minims  of  a  25  per  cent,  alcoholic  solution  of  nitrite  of 
ethyl,  mixed  with  two  drachms  of  water,  wTere  taken  by  the  patient. 
At  3  26'  30",  patient  said  he  was  "  not  so  ill." 

At  3  28',  at  both  the  right  and  the  left  sides,  there  were  rhonchi  with 
expiration,  sibili  had  disappeared,  and  no  accompaniments  were  heard 
with  inspiration.  The  time-relation  of  inspiration  to  expiration  was 
even  on  the  right  side,  1:1;  and  on  the  left,  f  :  1. 

At  3  31',  the  pulse  was  89  and  the  respirations  were  24  per  minute. 

At  3  35',  at  both  sides,  a  short  rhonchus  was  heard  with  inspiration, 
but  nothing  with  expiration.  There  was  also  only  slight  wheezing,  and 
the  patient  exclaimed,  "  I'm  almost  quite  easy  now." 

At  3  36'  30",  both  sides  of  the  chest  were  entirely  free  from  accom- 


FRASER,  DYSPNCEA   OF   ASTHMA    AND  BRONCHITIS.  405 


paniments.  The  time-relation  of  inspiration  to  expiration  was  at  the 
right  side  H :  1,  and  at  the  left  side  1  :  f. 

At  3  41',  the  pulse  was  72,  the  respirations  were  24  per  minute,  and 
the  breathing  was  still  quite  clear  and  free  from  accompaniments. 

At  3  51',  the  patient  remarked  that  he  was  "  quite  easy,"  and  had  "  no 
difficulty  in  the  least "  with  his  breathing ;  on  auscultation  no  accom- 
paniments were  anywhere  to  be  heard ;  there  was  no  wheezing ;  and  the 
time-relation  of  inspiration  to  expiration  was  1  :  f.  The  chest  was  fre- 
quently auscultated  from  this  time  until  4.50  a.m.,  and  the  breathing 
was  always  found  to  be  soft  and  vesicular  in  character  and  to  be  entirely 
free  from  rhonchi  or  sibili,  while  during  the  whole  of  this  time  the 
patient  remained  entirely  free  from  dyspnoea. 

At  4  52',  slight  wheezing  reappeared,  the  pulse  was  72  and  the  respi- 
rations were  20  per  minute ;  and  the  time-relation  of  inspiration  to 
expiration  was,  at  the  right  side,  1  :  1  i  :  and  at  the  left  side,  1:1. 

At  4  55',  at  the  left  side,  a  slight  sibilus  was  occasionally  heard  on  in- 
spiration, but  there  were  no  accompaniments  at  the  right  side. 

At  5  a.  M.,  the  auscultatory  phenomena  were  the  same  as  at  the  last 
note,  but  the  wheezing  was  more  audible,  and  expiration  seemed  slightly 
more  prolonged.  The  patient  coughed  at  this  time,  without  expecto- 
rating, however. 

At  5  11",  at  the  right  side,  there  was  slight  sibilus  at  the  beginning  of 
inspiration  with  loud  rhonchus  during  expiration,  and  at  the  left  side, 
while  inspiration  was  clear  there  were  rhonchi  with  expiration.  The 
breathing  was  now  a  little  embarrassed. 

At  5  18',  there  were  a  few  slight  rhonchi  and  sibili,  varying  much  in 
the  time  of  their  occurrence,  at  both  sides  of  the  chest.  The  patient  at 
one  time  said  the  breathing  "  is  quite  easy,"  and  at  another  that  it  was 
"  a  little  difficult."  The  pulse  was  78  and  the  respirations  were  24  per 
minute.    He  was,  however,  lying  in  a  normal  position  in  bed. 

These  conditions  remained  unchanged  until  5  25',  when  the  obser- 
vations were  stopped. 

Observation  IV. — An  observation  with  nitrite  of  ethyl  was  again 
made  on  this  patient,  on  the  24th  of  January,  1887.  On  this  occasion, 
the  first  symptoms  of  an  asthmatic  paroxysm  began  to  show  themselves 
soon  after  midnight. 

At  12  35'  A.  m.  the  patient  was  sitting  up  in  bed,  supporting  himself 
on  both  elbows,  and  breathing  with  great  difficulty.  He  stated  that  this 
difficulty  was  more  pronounced  during  expiration  than  inspiration. 
There  was  loud  wheezing,  audible  in  the  corridor  of  the  ward,  at  least 
thirty  yards  from  the  patient's  bed.  A  little  sputum  had  been  expec- 
torated, consisting  of  dark  masses  of  a  gelatinous  substance. 

At  12  40',  on  auscultation,  it  was  found  that  at  the  right  side  there 
were  numerous  rhonchi  and  sibili  with  both  inspiration  and  expiration ; 
and  that  at  the  left  side,  sibili  were  almost  continuous  through  inspira- 
tion and  expiration.  The  time-relation  of  inspiration  to  expiration  at 
both  sides  was  f  :U  .  The  pulse  was  79,  and  the  respirations  were  30 
per  minute. 

At  12  50',  the  patient  received  10  minims  of  a  25  per  cent,  alcoholic 
solution  of  nitrite  of  ethyl  in  a  little  water. 

At  12  51',  he  said,  "the  breathing  is  easier."  At  both  sides  rhonchi 
were  heard  during  both  inspiration  and  expiration,  but  there  were  no 


406     FR  A  SEE,  DYSPNCEA   OF  ASTHMA   AND  BRONCHITIS. 


sibili.  The  time-relation  of  inspiration  to  expiration  was  at  the  right 
side  f  :  f,  and  at  the  left  side  i  :  f . 

At  12  54',  the  wheezing  had  become  slight.  The  pulse  was  75  and 
the  respirations  were  24. 

At  12  57',  the  breath  sounds  were  at  both  sides  quite  clear,  almost 
vesicular  in  character,  and  entirely  free  from  accompaniments.  The 
time-relation  of  inspiration  to  expiration  was  at  the  right  side  1 :  f ,  and 
at  the  left  side  f  :  f . 

At  1  a.m.  there  was  no  wheezing,  and  the  breath  sounds  were  every- 
where vesicular  in  character.  The  patient  was  able  to  lie  down  in  a 
normal  posture.  The  pulse  was  72,  and  the  respirations  were  20  per 
minute. 

At  1  6',  at  the  right  side,  an  occasional  slight  and  distant  rhonchus 
was  heard  at  the  end  of  expiration,  and  on  the  left  side  a  similar  sound 
at  the  commencement  of  inspiration.    Slight  wheezing  was  also  audible. 

At  1  11',  the  conditions  were  the  same  as  at  1  6'. 

At  1  14',  patient  said  he  felt  "  quite  free  "  in  his  breathing.  The  pulse 
was  72,  and  the  respirations  were  20  per  minute. 

At  1  18',  the  patient  said  the  breathing  was  "  soft  as  if  it  was  oiled." 
There  were  no  accompaniments  on  auscultation;  the  wheezing  had  quite 
disappeared ;  and  the  time-relation  of  inspiration  to  expiration  was,  on 
both  sides,      :  li. 

The  patient  was  not  again  examined  until  2  a.m.  In  the  interval  he 
had  remained  perfectly  well,  and  free  from  any  difficulty  of  respiration. 
On  auscultation,  the  breathing  was  everywhere  vesicular  in  character  and 
without  any  accompaniment.  The  pulse  was  64,  and  the  respirations 
were  21  per  minute.  On  the  same  day  at  1  p.m.,  the  breath  sounds 
were  also  perfectly  normal ;  there  was  no  dyspnoea,  and  the  time-rela- 
tion of  inspiration  to  expiration  was  2  :  H. 

Observation  V. — This  patient  when  suffering,  on  another  occasion, 
from  a  severe  paroxysm  of  asthma,  was  treated  with  nitrite  of  sodium. 
The  paroxysm  began  to  manifest  itself  at  about  a  quarter  to  two  in  the 
morning  of  the  30th  of  December,  1886. 

At  2  54'  a.m.,  he  was  sitting  up  in  bed  in  great  distress,  suffering 
from  a  sense  of  great  straining  in  the  epigastrium,  and  he  was  wheezing 
as  loudly  as  before  the  other  observations  that  have  been  described. 
Sputum  of  a  very  tenacious  character  and  somewhat  blood-stained  was 
being  expectorated  with  great  difficulty.  The  pulse  was  feeble,  inter- 
mittent, and  extremely  varying  in  volume.  Its  rate  was  84,  and  that 
of  the  respirations  30  per  minute.  The  time-relation  of  inspiration  to 
expiration  was  1 :  24 

At  3  a.m.,  there  were  heard  on  auscultation,  at  the  right  side,  rhonchi 
throughout  inspiration  and  expiration ;  and  at  the  left  side,  coarse  rhonchi 
with  inspiration,  and  rhonchi  and  sibili  with  expiration.  Sibili  were 
apparently  also  being  produced  in  the  throat. 

At  3  2',  ten  minims  of  a  10  per  cent,  solution  of  nitrite  of  sodium, 
mixed  with  a  drachm  of  water,  were  given  to  the  patient. 

At  3  3',  the  right  side  was  almost  free  from  accompaniments,  but  at 
the  left  side  there  was  heard  a  faint  rhonchus  at  the  end  of  inspiration, 
and  an  occasional  faint  sibilus  at  the  end  of  expiration.  Patient  "  feels 
a  lot  easier." 

At  3  4',  wheezing  was  no  longer  audible,  and  the  patient  said  he  was 


FRASER,   DYSPNOEA   OF   ASTHMA    AND   BRONCHITIS.  407 


quite  easy,"  The  pulse  was  84  per  minute,  still  intermittent,  but  a 
little  fuller.    The  respirations  Avere  30  per  minute. 

At  3  6',  the  time-relation  of  inspiration  to  expiration  at  the  right  side 
was  l:f,  and  at  the  left  side  1:1. 

At  3  7',  the  patient  said  "  I  feel  nothing  at  all."  The  breathing  was 
quite  soft  and  subdued  at  both  sides,  and  there  were  no  accompaniments 
at  all. 

At  3  8',  there  was  slight  wheezing  in  the  throat,  but  the  breath 
sounds  over  the  lungs  were  perfectly  normal  and  vesicular. 

At  3  12',  the  patient  was  talking  quite  comfortably,  and  he  stated  that 
he  had  "  no  distress  whatever." 

At  3  13',  a  small  quantity  of  tenacious  sputum  was  expectorated,  which 
"  came  quite  easy." 

At  3  15',  the  breath  sounds  were  still  quite  free  from  accompaniments, 
except  that  a  few  crepitations  were  heard  at  the  beginning  of  inspira- 
tion over  the  right  lung.  The  time-relation  of  inspiration  to  expiration 
was  at  the  right  side  1 :  f ,  and  at  the  left  side  1 :  h 

At  3  17',  the  pulse  was  72  per  minute,  and  rather  more  intermittent 
than  formerly,  and  the  respirations  were  26  per  minute. 

At  3  20',  the  patient  continues  to  "  feel  nothing  at  all." 

At  3  28',  the  breathing  was  soft  on  both  sides  without  any  accompani- 
ment. The  time-relation  of  inspiration  to  expiration  was  at  both  sides 
1 : 1.    The  pulse  was  79,  and  the  respirations  were  25  per  minute. 

At  3  51',  the  conditions  were  the  same  as  at  last  note. 

At  3  53',  the  breathing  was  still  absolutely  clear  and  soft.  The  time- 
relation  of  inspiration  to  expiration  was  at  the  right  side  Xi:i,  and  at 
the  left  side  1 *  :  i. 

At  4  7',  the  condition  of  respiration  was  the  same. 

At  4  26',  the  breath  sounds  were  perfectly  soft  and  normal.  The  pulse 
was  72,  and  the  respirations  were  21  per  minute.  The  time-relationship 
of  inspiration  to  expiration  was  at  the  right  side  lj :  1,  and  at  the  left 
side  1 :  f  . 

The  observations  were  now  interrupted  until  5  53'  a.m.,  when  it  was 
found  that  slight  wheezing  was  again  audible,  and  that  over  both  lungs 
occasional  and  slight  rhonchi  and  sibili  were  present.  The  patient 
stated  that  about  five  minutes  previously  he  felt  tightness  of  the  chest 
and  wheezing  "  come  on  all  at  once." 

At  5  56',  there  were  faint  sibili  with  both  inspiration  and  expiration 
at  the  right  side,  and  with  inspiration  alone  at  the  left  side.  The  pulse 
was  78,  and  the  respirations  were  20  per  minute.  The  time-relation- 
ship of  inspiration  to  expiration  was  at  the  right  side  1 : 2,  and  at  the 
leftside  1 :  H. 

At  6  5',  the  patient  said  "  the  breathing  is  getting  tighter,"  and  the 
breath  is  "  worse  to  come  up  than  go  down."  Over  both  lungs  sibili 
were  heard  throughout  inspiration,  and  the  time-relation  of  inspiration 
to  expiration  was  at  both  sides  1 : 1  I . 

As  the  asthmatic  condition  was  obviously  returning,  after  an  absence 
of  at  least  two  hours  and  a  half,  it  appeared  of  interest  to  determine  if  the 
return  could  be  checked  and  a  normal  state  again  produced  by  a  second 
administration  of  nitrite.  The  dyspnoea  being  as  yet  but  slight,  it  seemed 
sufficient  to  administer  only  half  the  original  dose  of  nitrite  of  sodium. 

At  6  8',  therefore,  five  minims  of  the  same  10  per  cent,  solution,  or  half 


408     FRASER,  DYSPNffiA  OF   ASTHMA    AND  BRONCHITIS. 


a  grain,  of  nitrite  of  sodium  were  given  to  the  j>atient  in  a  drachm  of 
water. 

In  less  than  a  minute  he  exclaimed  "  its  away." 

At  6  9',  it  was  found,  on  auscultating,  that  all  accompaniments  had 
vanished  from  both  sides,  the  breathing  having  become  perfectly  soft. 
The  time-relation  of  inspiration  to  expiration  had  also  become  altered, 
for  at  the  right  side  it  was  1:1,  and  at  the  left  side  1  :  f,  showing  a  dimi- 
nution in  the  duration  of  expiration. 

The  patient  was  finally  seen  at  7  15'  a.m.  He  had  continued  quite  well 
since  he  had  received  the  second  dose.  There  had  been  no  wheezing, 
or  sense  of  tightness,  nor  any  form  of  difficulty  in  respiration.  On 
auscultating  over  both  lungs,  it  was  found  that  the  breath  sounds  were 
perfectly  clear  and  soft,  although  a  few  small  crepitations  occurred  early 
in  expiration  at  the  right  side.  The  pulse  was  78,  and  the  respirations 
were  24  per  minute.  The  time-relation  of  inspiration  to  expiration  was 
at  both  sides  1:1*. 

Observation  VI. — While  this  patient  was  suffering  from  a  severe 
attack  of  orthopnoea,  an  observation  was  made  on  him  with  nitroglycerine. 
The  attack  began  at  2  a.m.  on  a  damp  and  cold  night  (December  28, 
1886).  When  he  was  seen  at  2  35'  a.m.  he  was  sitting  upright  in  bed, 
holding  on  to  it,  and  breathing  with  extreme  difficulty,  the  difficulty 
being,  as  he  described  it,  during  both  inspiration  and  expiration.  There 
was  also  a  cough  w7hich,  after  great  and  prolonged  efforts,  brought  up 
sputa,  copious  in  amount,  muco-purulent,  stained  with  blood,  and  very 
tenacious.  It  was  found,  on  auscultation,  that  loud  and  continuous  sibili 
occurred  in  both  lungs  during  inspiration  and  expiration. 

At  2  41',  he  received  two  and  a  half  minims  of  a  one  per  cent, 
solution  of  nitroglycerine  diluted  with  a  drachm  and  a  half  of  water. 

Almost  immediately  thereafter  he  exclaimed,  "  Oh !  it's  easier,"  and 
the  wheezing  had  almost  disappeared  in  a  few  seconds  subsequently. 

At  2  42',  inspiration  and  expiration  were  in  both  lungs  very  much 
softer,  sibili  had  almost  disappeared,  slight  subdued  rhonchus  was 
heard  at  the  beginning  of  expiration,  and  there  were  some  crepitations. 
The  pulse  was  96,  and  the  respirations  were  36  per  minute. 

At  2  45',  at  the  right  side,  there  was  slight  rhonchus  throughout  in- 
spiration, and  at  the  left  side  short  rhonchus  at  the  beginning  of  inspira- 
tion.   The  pulse  was  78,  and  the  respirations  24  per  minute. 

At  2  47',  wheezing  had  again  become  audible,  an  attack  of  difficult 
coughing  occurred,  and  the  patient  stated  that  the  breathing  w^as  again 
tight,  but  in  a  few  seconds  afterwards  he  said  that  the  tightness  had  dis- 
appeared.   The  pulse  was  77,  and  the  respirations  24  per  minute. 

At  2  54',  the  breath  sounds  were  absolutely  clear,  soft,  and  vesicular, 
and  without  any  accompaniment. 

At  3  2',  while  the  breath  sounds  at  the  right  side  were  perfectly  nor- 
mal, at  the  left  side,  there  were  slight  distant  rhonchi  at  the  beginning 
of  inspiration  and  expiration.  The  patient  experienced  a  little  tightness 
of  breathing,  but  only  during  a  few  seconds. 

At  3  6',  at  both  ddes,  there  were  distant  sibili  throughout  inspiration 
and  expiration. 

At  3  10',  another  attack  of  violent  coughing  occurred,  when  a  little 
sputum  was  expectorated.  The  pulse  was  86,  and  the  respiration  24 
per  minute. 


FRASER,   DYSPNCEA   OF   ASTHMA   AND    BRONCHITIS.  409 


At  3  12',  there  was  again  marked  wheezing,  and  rhonchi  were  heard 
during  inspiration  and  expiration  over  both  lungs. 

The  observations  were  contined  until  5.35',  and  they  showed  a  gradu- 
ally increasing  development  of  breathlessness  and  of  the  respiratory 
accompaniments,  but  neither  attained  the  severity  and  urgency  which 
had  characterized  them  before  nitroglycerine  had  been  administered. 

Observation  VII. — The  effects  of  nitroglycerine  were  well  illustrated 
in  another  patient,  Thomas  H.,  thirty-six  years  of  age,  a  well-built, 
muscular  man,  a  joiner  by  occupation,  whose  illness  had  begun  about 
fourteen  weeks  before  the  observation  was  made.  There  was  no  history 
of  hereditary  predisposition  to  asthma,  and  no  personal  history  of  pul- 
monary disease,  with  the  exception  of  a  single  attack  of  acute  pneu- 
monia which  had  occurred  four  years  previously-  The  patient  referred 
the  origin  of  the  asthma  to  a  "  severe  cold,"  following  exposure  to  a  heavy 
rain.  A  week  afterward,  the  dyspnoea  appeared,  and  paroxysms  of  asthma 
occurred  regularly  every  morning  at  6  o'clock,  and  lasted  for  about 
three  hours.  He  also  had  considerable  dyspnoea  during  the  greater  part 
of  nearly  every  day,  and  especially  when  the  weather  was  foggy,  which 
prevented  him  from  working  or  going  about,  but  produced  no  discomfort 
while  he  was  at  rest  beyond  a, sense  of  tightness  and  weight  in  the 
chest.  He  was  free  from  cough  and  had  no  sputum,  excepting  when 
the  dyspnoea  was  present,  and  at  these  times  his  sputum  was  pretty 
copious,  watery,  and  frothy.  No  evidence  was  obtained  of  enlargement 
of  the  heart ;  but,  although  the  chest  was  well  formed,  the  lungs  were 
slightly  emphysematous.  Expansion  was  good,  expiration  was  a  little 
prolonged,  and,  generally,  rhonchi  and  sibili  with  medium  and  small 
crepitations  wTere  audible  over  the  greater  part  of  the  chest.  The  patient 
also  suffered  from  headaches,  which  occurred  in  the  morning  after  the 
commencement  of  each  paroxysm,  and  usually  disappeared  toward  the 
afternoon 

The  case  was,  therefore,  one  in  which  chronic  bronchitis  was  also 
present,  and  on  several  occasions  after  the  patient's  admission  into  the 
hospital  observations  were  made  while  there  were  no  paroxysms  of 
asthma  on  the  influence  of  nitrites  on  the  symptoms  of  bronchitis,  to 
some  of  which  I  shall  afterward  refer.  The  influence  of  nitrites  and  the 
conditions  in  which  the  patient  was  placed  in  the  hospital,  appeared  to 
lessen  the  severity  of  the  asthmatic  paroxysms  ;  they  became  less  fre- 
quent, the  time  of  their  occurrence  lost  the  regularity' it  had  originally 
possessed,  the  bronchitis  disappeared,  and  the  patient  was  dismissed 
on  December  26,  1886,  apparently  cured  of  both  asthma  and  bronchitis, 
as  he  had  had  no  symptoms  of  either  disease  for  ten  days. 

After  returning  to  his  home  in  Edinburgh,  he  remained  well  until  the 
28th  of  December.  On  that  day,  although  he  had  not  resumed  work  or 
undergone  any  exposure,  severe  dyspnoea  appeared  at  3  o'clock  in  the 
afternoon  and  continued  until  9  o'clock  on  the  following  morning.  He, 
therefore,  again  came  to  the  hospital,  and  was  readmitted.  He  remained 
free  from  dyspnoea  during  the  afternoon,  but  toward  eveniug  the  breath- 
ing gradually  became  difficult,  until  at  about  11  30'  p.m.  the  difficulty 
had  increased  to  orthopncea,  and  the  patient  was  obliged  to  sit  upright  in 
bed,  supporting  himself  with  his  extended  arms. 

At  1 12'  a.m.,  the  patient  was  in  great  distress,  feeling,  as  he  said,  "  like 
to  choke."  He  stated  that  the  difficulty  in  breathing  was  felt  chiefly 
during  expiration.    He  had  spat  a  small  quantity  of  slightly  adhesive 


410     FRASER,  DYSPNCEA   OF   ASTHMA    AND  BRONCHITIS. 


sputum.  There  was  loud  wheezing,  and  wThen  the  chest  was  auscultated 
sibili  were  heard  throughout  inspiration  and  expiration  at  both  sides, 
completely  masking  all  other  sounds.  The  pulse  was  112,  and  the 
respirations  30  per  minute.  The  time-relation  of  inspiration  to  expira- 
tion was  1:3. 

At  1  20',  he  received  five  minims  of  a  one  per  cent,  solution  of  nitro- 
glycerine mixed  with  two  drachms  of  water.  There  was  a  perfect 
"  storm  "  of  accompaniments  when  the  nitroglycerine  was  given.  In 
less  than  thirty  seconds  he  said,  "  I  feel  a  little  easier." 

At  1  21'  30",  the  wheezing  was  less  audible,  and  at  the  left  side  in- 
spiration was  almost  clear,  but  there  were  rhonchi  with  expiration. 

At  1  23',  the  breathing  was  almost  clear  at  the  right  side,  and  there 
was  a  brief  sibilus  on  expiration  at  the  left  side.  Patient  said  he  "  feels 
much  easier." 

At  1  23'  30",  at  the  right  side  there  were  sibili  during  expiration,  and 
at  the  left  side  sibili  during  inspiration.  The  pulse  was  114,  and  the 
respirations  were  30  per  minute. 

At  1  26',  headache  came  on. 

At  1  27',  he  expectorated  about  half  an  ounce  of  frothy  and  slightly 
tenacious  sputum. 

At  1  28',  at  the  right  side  both  inspiration  and  expiration  were  vesi- 
cular and  free  from  accompaniments,  and  at  the  left  side  inspiration  was 
perfectly  clear,  but  very  slight  rhonchus  occurred  with  expiration.  The 
wheezing  was  scarcely  audible,  and  the  patient  said  he  was  "  a  great  deal 
easier." 

At  1  31',  the  pulse  was  108  and  the  respirations  were  30  per  minute. 
The  patient  said  the  difficulty  of  expiration  was  "  nothing  to  speak  of." 

At  1  34',  the  breathing  was  at  times  perfectly  free  from  accompani- 
ments, and  then  for  a  few  seconds  sibili  or  rhonchi  were  heard  on  one 
or  other  side  of  the  chest.  The  pulse  was  108  and  the  respirations 
were  28  per  minute.  The  time-relation  of  inspiration  to  expiration 
was  1 : 21. 

At  1  38',  the  chest  was  beginning  to  feel  tight,  and  the  wheezing  was 
distinctly  audible. 

At  1  42',  the  breathing  had  become  "  a  great  deal  stiffer ;"  the  diffi- 
culty, according  to  the  patient,  was  in  "  getting  out  breath."  Over  both 
lungs  rhonchi  and  sibili  were  heard  during  inspiration  and  expiration. 

At  1  50',  the  above  sounds  were  only  occasionally  heard,  and  the 
patient  said  he  "feels  as  free  as  ever  he  was,"  and  his  appearance  was 
again  that  of  ease. 

At  2  2',  2  14',  2  27',  and  2  44',  the  auscultatory  phenomena  continued 
as  at  last  note.  At  2  14',  the  pulse  was  106  and  the  respirations  were  24 
per  minute ;  and  at  2  27',  they  were  80  and  25  per  minute,  respectively. 

At  2  58',  the  time-relation  of  inspiration  to  expiration  was  at  the  right 
side  1:1,  and  at  the  left  side  H:2J.  The  character  of  the  breathing 
was  soft,  but  now  and  again  a  brief  sibilus  was  heard,  with  small  crepi- 
tations at  the  end  of  expiration. 

At  3  15'  and  3  57',  the  conditions  remained  as  at  the  last  note.  At 
the  latter  time  the  pulse  was  80  and  the  respirations  were  29  per  minute; 
and  the  time-relation  of  inspiration  to  expiration  was,  at  left  side,  1 : 2. 

The  patient  was  now  left  to  himself,  apparently  free  from  any  obvious 
sign  of  dyspnoea,  but  still,  on  being  asked,  confessing  to  a  sensation  of 
slight  constriction  in  the  chest. 


FE  AS  ER,  DYSPNCE  A   OF   ASTHMA    AND  BRONCHITIS.  411 


When  he  was  again  seen,  at  4  30'  and  5  20'  a.m.,  he  was  sound  asleep 
and  breathing  quietly  and  without  wheezing. 

Observation  VIII. — The  last  case  I  shall  describe  is  one  which 
illustrates  the  close  relationship  frequently  observed  between  bronchitis 
and  asthma.  The  patient  was  a  man,  James  B.,  fifty-two  years  of  age, 
presenting  the  ordinary  symptoms  of  pronounced  emphysema  and  severe 
bronchitis,  and  suffering  greatly  from  frequent  periodic  attacks  of  dys- 
pnoea and  orthopnoea.  The  bronchitis  was  manifested  by  coarse  and 
medium  crepitations,  continuous  rhonchi  and  sibilations,  and  severe 
cough,  accompanied  with  an  abundant  muco-purulent  and  frothy  sputum. 
The  asthma  manifested  itself  in  paroxysms  of  urgent  orthopnoea,  occur- 
ring during  the  night  and  almost  every  night,  and  so  prolonged  that  the 
patient  could  not  obtain  sleep,  except  in  the  morning  and  during  the 
day. 

On  the  8th  of  January,  1885,  one  of  the  usual  paroxysms  began  at 
9  p.m.  He  was  seen  immediately  afterward,  when  he  was  sitting  up  in 
bed  in  great  distress,  with  loud  wheezing  respiration ;  and  it  was  found 
that  rhonchi  and  sibili  were  abundantly  present. 

At  9  30'  p.  m.,  a  pulse  tracing  was  taken,  the  pulse  being  64  and  the 
respirations  21  per  minute.    (Fig.  12.) 

Fig.  12. 


James  B.    Before  nitrite  of  sodium.    Pulse  64,  respirations  21  per  minute. 


At  9  35',  five  grains  of  nitrite  of  sodium  dissolved  in  one  drachm  of 
water,  were  administered. 

Almost  immediately  afterward  the  patient  felt  some  peculiar  sensa- 
tions, which  he  described  as  "  the  medicine  going  all  over  him  and 
making  him  feel  queer."  In  the  course  of  a  few  minutes  the  dyspnoea 
was  relieved,  the  rhonchi  and  sibili  had  entirely  disappeared,  and  the 
respiratory  movements  were  more  full  and  more  easily  performed.  The 
patient  soon  lay  down  on  the  bed  and  seemed  disposed  to  sleep. 

The  pulse  showed  the  following  characters  at  thirty  minutes,  at  one 
hour,  and  at  one  hour  and  a  half  after  the  nitrite  had  been  administered. 
(Figs.  13,  14,  and  15.) 


Fig.  13.  Fig.  14. 


James  B.    Thirty  minutes  after  nitrite  of  James  B.    One  hour  after  nitrite  of  sodium, 

sodium.    Pulse  76,  respirations  20  per  minute.  Pulse  76,  respirations  18  per  minute. 

The  chest  was  frequently  auscultated,  and  it  was  found  to  remain  free 
from  rhonchi  and  sibili  during  two  hours  succeeding  the  administration. 
After  this  time  rhonchi  were  again  heard,  but  only  in  a  subdued  form. 
The  patient,  however,  was  so  greatly  relieved  in  his  breathing  that  he 


412     FEASEE,  DYSPNffi  A   OF   ASTHMA   AND  BRONCHITIS. 

slept  whenever  he  was  left  undisturbed,  and  he  remained  free  from  dys- 
pnoea all  night. 

At  two  hours  and  at  four  hours  after  the  administration,  the  pulse 
possessed  the  characters  represented  in  the  next  tracing.    (Fig.  16.) 


Fig.  15.  Fig.  16. 


James  B.    One  hour  and  a  half  after  nitrite  James  B.    Four  hours  after  nitrite  of  sodium, 

of  sodium.     Pulse  72,   respirations  17  per  Pulse  64,  respirations  18  per  minute, 

minute. 

On  other  occasions  similar  satisfactory  results  were  obtained  on  this 
patient  with  nitrite  of  sodium  and  also  with  nitroglycerine.  The 
latter,  however,  several  times  produced  severe  headache,  and,  therefore, 
nitrite  of  sodium  was  more  frequently  given.  While  five-grain  doses  of 
it  in  a  most  marked  manner  subdued  the  severe  paroxysms  of  dyspnoea 
— the  patient  on  one  occasion  stating  that  he  would  have  died  had  the 
medicine  not  relieved  him — it  did  not  cause  any  headache.  At  the  same 
time,  it  was  found  that  the  dyspnoea  could,  in  this  patient,  generally  be 
relieved  by  one  or  two  grain  doses.  One  administration,  but  only  one 
out  of  a  considerable  number,  of  five  grains  was  followed  by  toxic  symp- 
toms, consisting  mainly  of  great  feebleness  of  the  circulation,  which, 
however,  quickly  disappeared  after  the  administration  of  a  little  brandy. 

The  administration  by  the  stomach  of  nitrite  of  amyl,  nitrite  of  ethyl, 
nitrite  of  sodium,  and  nitroglycerine,  therefore,  produced  the  same  kind 
of  effect  on  asthma  as  that  which  followed  the  administration  by  inhala- 
tion of  the  volatile  of  these  nitrites.  A  marked,  and  for  therapeutic 
purposes  a  very  important  difference,  was  manifested  in  the  duration  of 
these  effects,  which  were  greatly  prolonged  by  stomach  administration. 

It  has  been  well  recognized  that  the  auscultatory  phenomena  which 
have  been  referred  to,  are  present  during  the  asthmatic  paroxysm.  It 
does  not  appear  to  have  been  distinctly  appreciated  that  they  are  so 
intimately  associated  with  the  paroxysms,  that  dyspnoea  is  present  only 
while  they  are  present,  and  that  it  subsides  or  disappears  only  when 
they  subside  or  disappear.  Not  only  has  this  been  rendered  apparent 
by  the  observations  I  have  described,  but  also  by  an  observation  in 
which  the  exceptional  result  was  obtained,  that  a  nitrite  administered 
during  a  severe  asthmatic  paroxysm,  failed  to  produce  more  than  an 
insignificant  and  temporary  improvement  in  the  dyspnoea,  and  equally 
failed  to  subdue  more  than  to  a  slight  extent,  and  for  a  brief  period, 
the  loud  rhonchi  and  sibili  that  were  present. 

The  observations  that  have  been  described  further  show  that  both 
the  dyspnoea  and  the  sounds  in  the  chest  can  be  made  to  disappear 
simultaneously,  or  nearly  so,  by  substances  whose  action  is  to  reduce, 


Fit  ASER,   DYSPNCB  A   OF   ASTHMA    AND   BRONCHITIS.  418 


powerfully,  the  contractility  of  non-striped  muscle.  It  appears  to  follow 
from  this  that  the  dyspnoea  of  asthma  is  caused  by  spasm  of  the  bronchial 
muscles. 

The  view  that  this  dyspnoea  finds  its  chief  explanation  in  spasm  of  the 
diaphragm,  associated  or  not  associated  with  spasm  of  the  ordinary  mus- 
cles of  respiration  has,  as  I  have  already  stated,  received  so  damaging  a 
criticism  from  Biermer,  that  its  further  refutation  by  such  observations 
as  have  been  brought  forward  seems  to  be  almost  unnecessary.  The  re- 
maining view  to  which  any  importance  may  be  attached,  that,  namely,  of 
constriction  of  the  bronchial  tubes  by  swellings  of  a  hypersemic,  herpetic 
or  urticaria-like  character — whose  most  prominent  upholders  are  Weber 
and  Sir  Andrew  Clark — presupposes  for  the  production  of  the  swellings 
a  dilated  state  of  the  bloodvessels  of  the  bronchial  tubes.  The  means 
which  I  have  successfully  employed,  however,  for  controlling  and  check- 
ing the  asthmatic  paroxysm  are  the  very  means  which  should,  according 
to  this  theory,  be  the  most  efficient  that  could  have  been  selected  for  in- 
creasing the  paroxysm  and  rendering  it  more  prolonged.  There  is  no 
fact  in  pharmacology  more  certain  and  undoubted  than  that  nitrites 
produce  rapid  and  great  dilatation  of  the  bloodvessels  throughout  the 
body.1  In  the  first  observation  I  brought  forward,  and  I  have  others  of 
a  like  kind,  this  dilatation  was  produced  at  the  moment  when  the  dys- 
pnoea disappeared ;  it  was  maintained  while  the  dyspnoea  was  absent ;  and 
it  gave  place  to  a  normal  condition  of  the  bloodvessels  when  the  dyspnoea 
returned.  It  seems,  therefore,  to  have  been  abundantly  shown  that  the 
theory  of  the  production  of  asthmatic  dyspnoea  by  swellings  of  the  bron- 
chial mucous  membrane  of  a  hypersemic  or  inflammatory  kind  can  no 
longer  be  maintained. 

The  conceptions  of  the  conditions  that  immediately  produce  the  asth- 
matic dyspnoea  or  orthopnoea,  have  been  obscured  by  the  numerous  and 
unharmonizing  theories  that  have  been  propounded.  If  the  results  of 
the  observations  I  have  brought  forward  should  produce  the  impression 
upon  others  which  they  have  produced  upon  me,  I  believe  these  obscuri- 
ties will  to  a  great  extent  disappear,  and  the  old  doctrine  that  the  asth- 
matic paroxysm  depends  immediately  upon  spasm  of  the  bronchial  mus- 
cles, will  be  more  firmly  established  in  the  position  which  it  had  formerly 
occupied.  At  the  same  time,  it  is  not  to  be  supposed  that  this  doctrine 
is  incompatible  with  the  view  that,  in  a  secondary  manner,  and  as  a  re- 
sult probably  of  the  dyspnoea  which  has  already  been  caused  by  con- 
tractions of  the  bronchial  muscles,  spasmodic  contractions  may  also  be 

1  Although  it  has  not  been  proved  by  direct  observation  that  nitrites  dilate  the  bloodvessels  on  the 
surface  of  the  bronchi,  there  is  no  reason  to  doubt  that  they  do  so  ;  while  the  facts  that  these  bloodvessels 
are  derived  from  the  aorta  and  intercostal  arteries,  and  that  they  possess  the  same  structure  as  the 
other  bloodvessels  of  the  systemic  circulation  afford  a  strong  presumption  in  favor  of  their  being 
dilated  by  nitrites  in  common  with  the  other  bloodvessels  of  this  system. 


414     FRASER,  DYSPNOEA   OF   ASTHMA   AND  BRONCHITIS. 

originated  in  the  diaphragm  and  in  other  of  the  ordinary  muscles  of 
respiration. 

The  success  in  any  disease  of  a  therapeutic  agent  whose  action  is  a 
known  one  affords  valuable  evidence  of  the  correctness  of  the  theory  of 
the  causation  of  that  disease.  Such  evidence  appears  to  be  afforded  in  a 
very  incisive  manner  by  the  influence  of  nitrites  in  asthma.  In  this 
disease  many  other  remedies  have  also  been  found  to  produce  benefit. 
Probably  this  benefit  has  been  more  markedly  associated  with  the  inha- 
lation of  the  smoke  of  certain  solanaceous  plants,  of  nitre,  and  of  several 
patent  medicines  in  the  form  of  powders,  than  with  any  other  remedies. 
The  cause  of  the  benefit  which  these  substances  produce  is,  however, 
almost  unknown,  and  such  speculations  have  been  advanced  as  those  of 
Oertel  in  his  Treatise  on  Respiratory  Therapeutics}  that  the  fumes  of 
stramonium  and  of  nitre  are  beneficial  because  they  stimulate  the  air 
passages,  giving  rise  to  violent  coughing  and  copious  expectoration, 
and  not  because  they  act  ansesthetically  and  antispasmodically  on  the 
bronchioles  and  lungs.  Their  influence  upon  the  essential  phenomena 
of  asthma,  and  especially  upon  those  phenomena  that  imply  spasm  of 
the  bronchial  tubes,  has  not,  indeed,  been  investigated,  nor  is  there 
much  knowledge  as  to  the  composition  of  the  patent  asthma  remedies. 
The  extensive  use  of  these  remedies  suggests  that  advantage  must  be 
gained  from  their  employment ;  and  it  is  a  common  experience  to  meet 
with  patients  who  have  a  greater  faith  in  their  power  to  give  relief, 
than  in  the  arsenic,  or  iodide  of  potassium,  or  lobelia  which  may  be 
recommended  to  them  by  their  medical  advisers.  So  much  have  I 
been  impressed  with  this  circumstance,  that  I  have  procured  several  of 
these  patent  medicines  for  the  purpose  of  having  their  composition,  and 
the  composition  of  the  products  of  their  combustion,  determined.  This 
has  been  done  for  me  by  my  assistant  Dr.  Atkinson,  with  the  results 
noted  in  the  subjoined  table. 

Arsenic  was  searched  for  in  all  of  the  preparations,  but  was  not  dis- 
covered in  any  of  them.  Nitrites  were  not  found  in  the  smoke  of  any 
of  the  cigarettes  examined  ;  but  of  the  other  preparations,  in  66  per  cent, 
the  products  of  combustion  contained  nitrites,  and  in  large  quantity  in 
50  per  cent,  of  them. 

While  these  results  supply  a  sort  of  confirmation  to  the  value  of 
nitrites  in  asthma,  which  the  observations  that  have  been  described  so 
strongly  suggest,  it  is  undoubtedly  the  case  that  the  best  therapeutic 
effects  are  not  obtained  by  the  inhalation  of  nitrites,  but  by  their  ad- 
ministration through  the  stomach.  The  facts  that  have  been  stated 
seem  to  justify  the  assertion  that  their  administration  in  this  manner  in 
asthmatic  dyspnoea  or  orthopnoea  is  entitled  to  rank  as  one  of  the  most 
valuable  of  the  applications  of  pharmacology  to  the  treatment  of  disease, 

1  Von  Ziemssen's  Handbook  of  General  Therapeutics,  translated  by  J.  Burney  Yeo,  M.D.,  1885, 
vol.  iii.  p.  178. 


MITCHELL,  NEUKALGIC  HEADACHES. 


415 


an  application  at  least  as  valuable  as  that  in  the  painful  angina  of  aortic 
disease,  to  which  nitrites  are  at  present  almost  restricted. 


Before  burning  :  i 

MADE    WITH  WATER 

N  FUSION 
CONTAINS 

After  burning:  smoke 

CONTAINS 

Nitrite. 

Nitrate. 

Pupil 
dilator. 

Nitrite. 

Pupil 
dilator. 

1.  Maokill's  Asthma  Cure  (Hamilton)  . 

None 

Distinctly 

Distinctly 

Distinctly 

Distinctly 

2.  Himrod's  Asthma  Cure  (Himrod  Manu- 
facturing Co.) 

I 

Abundantly 
Distinctly 

Abundantly 
Distinctly 

4.  Senier's  Asthma  Remedy  (London  and 

Milwaukee.) 

5.  Green  Mountain  Asthma  Cure   .    .  . 

Trace 

None 

« 

Distinctly 

Distinctly 

« 

7.  Girdwood's  Patent  Asthma  Cure  (Bel- 

fast.) 

8.  Edward's  "  Yalley  Moss  "  Asthma  Cure 

Trace 

„ 

None 

» 

9.  Ozone  Paper  (Huggins,  London).     .  . 

None 

.A.t)  \i  n  d  3.  n  1 1  v 

10.  Hockin's  Remedy  for  Asthma  and  Bron- 
chitis (Ryde,  Isle  of  Wight ) 

11  Papier  Fruneau  contre  l1  \stbme  (Frun- 
eau,  Nantes.) 

12.  Dr.    Palmer's    Antiasthmatic  Papers 

(Simpson  &  Co.,  Dublin.) 

13.  Joyes'  Cigares  Antiasmatiques    .    .  . 

None 
Abundantly 

Trace 

Distinctly 
Distinctly 

None 
Abundantly 

None 

Distinctly 
None 

Distinctly 

14.  Argo  Cigarettes  (Blair,  Perth).    .    .  . 

Faint  trace 

15.  Cigarettes  Indiennes  (Grimault  &  Cie., 

Paris. ) 

16.  Kay's  Stramonium  Cigarettes  (Stock- 

port) 

17.  Dr.  Douglas's  Maori  Cigarettes  (Perth) 

None 
Trace 

Trace 
Distinctly 

<< 

Faint 
trace 
Distinctly 

18.  Marshall's  Cubeb  Cigarettes  (Horner, 
New  York.) 

None 

Trace 

Faint 
trace 

NEURALGIC  HEADACHES  WITH  APPARITIONS  OF  UNUSUAL 

CHARACTER. 

By  S.  Weir  Mitchell,  M.D., 

PHYSICIAN  TO  THE  INFIRMARY  FOR  NERVOUS  DISEASES,  PHILADELPHIA. 

The  peculiar  cases  of  migraine  I  am  about  to  describe  must  be  exces- 
sively rare  in  either  of  their  varieties,  since,  with  the  largest  opportuni- 
ties, I  have  seen  in  all  but  four  examples.  These  are  so  interesting 
that  they  possess  a  value  which  sets  them  quite  above  the  position  of 
mere  rarities;  perhaps  their  relation  may  call  forth  from  others  the 
statement  of  like  cases.  In  the  cases  I  shall  describe,  the  ordinary  sub- 
jective images  of  zigzag  lines  or  rotating  wheels  were  replaced  by  more 
definite  shapes,  so  as  sometimes  to  induce  the  belief  for  a  time,  on  the 
part  of  the  patient,  that  a  ghost  has  been  seen.  In  two  persons  the 
vision  came  as  the  only  visual  prodrome  of  severe  headaches.  In 


416 


MITCHELL,  NEURALGIC  HEADACHES. 


another  the  appearances  were  various ;  at  times  followed  the  common 
zigzags,  and  at  others  occurred  in  the  intervals  between  a  succession  of 
exasperating  headaches.    I  describe  first  the  lighter  cases. 

Case  I. — Miss  W.,  aet.  thirty,  was  in  good  general  health  and  able  to 
bear  great  fatigue,  and  to  use  her  mind  and  body  incessantly  as  a  teacher. 
About  once  a  week  for  many  years  she  had  attacks  of  migraine  of  great 
severity.  When  nineteen  years  old  she  began,  just  before  the  headaches, 
to  see  a  bright  gold-tinted  cloud,  and  with  it  an  appearance  of  parti- 
colored rain.  There  was  most  clouding  of  vision  when  the  sequent  pain 
was  over  the  right  eye,  and  these  visual  phenomena  were  not  constant. 
Somewhat  later  she  had  for  months  permanent  headache  on  the  vertex 
only,  and  now  and  then  the  addition  of  ophthalmic  migraine. 

When  twenty-eight  years  old,  and  still  subject  to  prolonged  headache, 
the  attacks  changed  their  type.  After  a  few  weeks  of  freedom,  one  day, 
when  going  up  stairs,  she  was  abruptly  aware  of  being  accompanied  on 
her  left  by  a  large  black  and  very  hairy  dog.  In  some  alarm  she  ran 
into  a  room  and  sat  down,  but  still  found  the  dog  beside  her.  Being  a 
woman  of  courage,  she  put  out  her  hand  to  touch  it,  but  could  feel 
nothing,  although  her  ghostly  companion  was  still  perfectly  visible.  At 
this  moment  a  severe  pain  began  over  the  left  eye,  and  the  dog  was 
gone. 

These  attacks  recurred  at  intervals,  as  well  as  the  now  ordinary  brow 
pain  without  the  dog  vision,  but  the  dog  headaches,  as  she  called  them, 
were  always  the  most  severe.  The  visual  symptoms  left  her  after  some 
years,  but  as  she  went  abroad  to  live,  I  lost  sight  of  her  altogether  for 
a  time.  I  have  since  heard  that  in  middle  life  her  headaches  left  her 
altogether.  I  should  add  as  a  curious  detail  that  nearly  always,  but  not 
inevitably,  the  dog  appeared  as  she  was  going  up  stairs. 

Case  II.  is  very  interesting.  Mrs.  C,  of  Arkansas,  set.  thirty-eight, 
mother  of  four  children,  consulted  me  on  account  of  a  condition  of  great 
prostration  which  had  lasted  for  years,  and  was  due  to  exhausting  lacta- 
tion subsequent  to  excessive  hemorrhage  at  the  birth  of  her  last  child. 
She  had  been  a  strong  and  vigorous  woman,  and  with  extreme  weakness 
and  great  anaemia  had  no  organic  malady.  She  had  been  unusually 
free  from  headaches.  In  the  fourth  month  of  her  lactation  she  was 
dressing  in  front  of  a  mirror,  when  she  was  suddenly  aware,  as  she 
turned  to  the  left,  of  the  presence  beside  her,  in  full  daylight,  of  her 
sister  who  had  been  dead  for  several  years.  In  great  terror  she  turned 
to  see  her,  and  found  that,  as  she  did  so,  the  figure  moved,  keeping  the 
same  relation  to  her  as  when  first  observed.  She  staggered  to  the  bed 
and  fell  upon  it.  When  presently  she  opened  her  eyes  the  figure  was 
gone,  and  she  was  at  once  conscious  of  a  violent  pain  over  the  left  eye, 
a  pain  which  lasted  for  many  hours,  and  wound  up  with  an  attack  of 
nausea  and  a  great  flow  of  pale  urine. 

For  some  time  she  was  supposed  to  have  had  sight  of  a  ghostly  visit- 
ant. A  month  later,  in  her  drawing-room  with  people  about  her,  she 
again  saw  the  same  spectral  form,  and  once  more  had  a  headache.  Until 
this  sequence  occurred  several  times,  she  laid  the  headache  to  the 
ghost,  and  not  the  ghost  to  the  headache,  as  she  learned  to  do  after  the 
phenomena  had  been  many  times  repeated.  When  I  saw  her  she  still 
had  migraine,  but  usually  on  the  right  side,  and  without  the  spectre, 
but  the  rarer  left-sided  headaches  were  always  preceded  by  an  apparition 


MITCHELL,  NEUKALGIC  HEADACHES. 


417 


of  her  sister  dressed  for  the  street  in  a  bonnet.  She  thinks  that  with 
closed  eyes  the  vision  becomes  less  distinct,  but  to  cover  the  right  eye 
only  makes  no  difference. 

Case  III. — Miss  J.,  set.  thirty-eight,  of  New  Hampshire,  was  one  of  a 
family  doomed  to  a  variety  of  grave  neuroses.  Two  brothers  died  of 
epilepsy,  and  two  sisters  had  been  insane.  Neuralgic  headaches  were 
inherited  by  all  of  them.  At  the  age  of  thirty  she  became  hysterical, 
and  for  three  years  suffered  with  losses  of  power,  spasms,  and  hemi- 
analgesia.  The  accustomed  headaches  went  on  as  usual,  but  with  the 
addition  of  one  horrible  symptom,  which  was  never  constant,  and,  in 
fact,  was  rare  unless  the  headache  came  at  her  menstrual  period. 
Usually  the  type  was  congestive.  A  slight  blur  of  vision  was  followed 
by  a  neuro-paralytic  state  of  the  temporal  arteries,  flushed  face,  and 
within  a  half  hour  violent  pain  over  and  under  one  eye,  and  later  in  all 
parts  of  the  head.  A  rare  form  of  pain  preceded  the  monthly  flow,  and 
was  ushered  in  by  a  ruddy,  indistinct  spot,  like  mist,  through  which,  as  it 
grew,  she  still  saw  the  dim  outlines  of  objects.  The  attacks  were  on 
either  side,  and  the  visual  phenomena  alike.  A  few  months  later  the 
red  blur  took  suddenly  the  form  of  a  near  relative,  who  appeared  to  her 
covered  with  blood,  and  wearing  an  expression  of  profound  melancholy. 
The  headache  followed  the  spectral  apparition  within  a  few  moments, 
and  as  it  increased  with  acute  pain  over  either  eye  the  figure  faded,  but 
left  her  for  some  days  with  an  agonizing  desire  to  kill  the  person  whose 
image  she  had  seen.  As  she  was  profoundly  attached  to  this  relative, 
the  conflict  between  her  morbid  impulse,  which  was  at  times  almost 
uncontrollable  and  her  very  distinct  sense  of  the  sin  of  yielding,  became 
most  painful  to  witness.  As  time  went  on  the  apparition  became  more 
frequent,  and  was  seen  at  intervals  during  the  entire  period  of  menstrual 
flow.  Meanwhile  her  mind  grew  weaker,  and  a  profound  melancholia 
affected  her  for  two  weeks  after  menstruation,  to  recur  with  brow  pain 
and  spectral  illusion  at  the  next  period.  At  last,  after  all  manner  of 
treatment  had  been  used  in  vain,  both  ovaries  were  removed,  with  the 
best  possible  results.  The  headaches,  hysteria,  and  spectral  appearances 
left  her  by  degrees.  At  first,  for  some  months,  they  occurred  in  milder 
and  yet  milder  forms  once  a  month,  and  at  last  disappeared.  The  mel- 
ancholy lessened,  and  after  a  year  ceased  to  exist,  and  left  her  in  a  con- 
dition of  absolutely  perfect  health  of  mind  and  body. 

The  last  case  I  have  to  state  is,  of  all,  the  most  valuable,  and  of  it  I 
have  the  fullest  account. 

Case  IV. — E.  C,  male,  set.  thirty,  of  New  Jersey,  weight  168,  not 
anaemic.  Has  never  had  syphilis.  The  urine  is  normal,  but  pale  and 
in  excess  after  an  attack.  All  the  organs  are  healthy,  or  at  least  seem 
to  be  free  from  organic  disease. 

He  is  a  man  of  active  intelligence  and  has  for  many  years  been  sub- 
ject to  the  incessant  strain  of  a  business  which  clearly  overtasks  his 
strength — nevertheless,  he  sleeps  well  as  a  rule.  His  memory  is  irood 
and  his  mind  clear  for  brief  work,  but  he  has  become  increasingly  irri- 
table. He  is  of  late  years  rarely  free  from  pain  in  some  part  of  the 
head,  but  has  hemicrania  which  occurs  at  intervals  of  weeks  or  as  for 
apart  as  three  months,  and  has  existed  with  ophthalmic  symptoms  since 
youth  save  for  a  period  of  fifteen  years,  its  return  being  consequent  to 
typhoid  fever  in  1865. 

NO.  CLXXXVIII.—  OCTOBER,  1887.  27 


418 


MITCHELL,  NEURALGIC  HEADACHES. 


Anger,  worry,  prolonged  use  of  the  eyes  in  near  work  are  the  parents 
of  attacks,  or  of  what  we  may  call  the  cephalalgic  status  which  lasts 
two  or  three  weeks  and  gives  rise  to  one  or  more  acute  headaches  daily. 

The  symptoms  of  onset  are  these,  frontal  and  occipital  sense  of  tension 
lessening  toward  night,  good  sleep  follows,  next  day  he  awakens  wTith 
some  pain  between  the  eyes  and  slight  photophobia.  The  second  night, 
or  the  morniug  after  it,  he  is  aware  of  being  flushed,  but  has  no  cerebral 
throbbing.  In  a  few  moments  the  lids  feel  as  if  pulled  toward  the  inner 
canthus  and  fortification  zigzags  appear,  with  next  partial  blurring  of 
vision  which  seems  in  twenty  minutes  to  efface  the  lines  and  include 
more  or  less  of  the  field.  The  lines  seem  to  be  projected  one  inch  from 
the  eye,  and  flash,  and  come  and  go  with  shimmering  prismatic  colors. 
The  dimming  of  vision  lasts  some  twenty  minutes  and  leaves  him  with 
slight  vertigo  and  a  feeling  of  fulness  of  the  head,  but  pain  always  begins 
over  the  eye  which  has  distinct  vision,  and  of  this  he  is  sure.  It 
increases  as  the  eyesight  clears,  and  is  about  one  inch  above  the  eye. 
Exertion,  stooping,  anxiety  increase  it.  The  pain  lasts  from  one  to  three 
hours  and  ceases  without  nausea.  When  it  occurs  over  the  left  eye  he 
has  sometimes  slight  aphasia  for  five  minutes,  and  in  youth  this  was 
more  severe  and  more  lasting. 

As  the  zigzags  fade  he  has  exalted  sense  of  hearing ;  loud  voices  hurt 
him  for  a  half  hour,  and  this  is  the  period  of  vertigo.  At  one  time 
he  had  at  this  period  of  the  attack  tingling  in  the  fingers  of  the  side 
opposite  to  that  of  the  pain.  After  a  number  of  these  headaches  he 
is  subject  to  the  curious  and  exceptional  illusions  wdiich  have  caused 
me  to  report  his  case.  At  times  these  replace  the  zigzag  lines,  but  later 
in  a  series  of  headaches  they  come  on  independent  of  the  hemicrania 
and  occur  at  night,  wdiile  awake  or  in  full  daylight. 

1.  A  common  delusion  with  him  is  to  see  about  twenty  feet  distant  a 
trellis  of  silver  covered  with  vines  and  flowers  of  brilliant  tints.  This 
is  seen  best  when  the  eyes  are  open,  and  comes  and  goes. 

2.  He  sees  a  series  of  complex  geometrical  figures  at  the  centre  of 
the  field.    These  are  brilliant  pink  or  red. 

3.  Quite  commonly  he  sees  multiple  red  circles  intertwined  and  in 
rapid  rotation,  and  once  a  red  eye  which  seemed  to  approach  him  from 
a  distance.    Sometimes  there  is  a  milky  cascade  before  both  eyes. 

4.  He  saw  once  a  crescent  of  silver  on  the  wall  and  suspended  from 
it  numerous  heads  in  profile.  Some  were  strange  to  him  and  some  were 
vivid  revivals  of  faces  which  he  had  long  forgotten. 

5.  Six  years  ago,  he  saw,  during  an  attack,  a  huge  red  spider,  which 
melted  into  a  series  of  red  rectangles  revolving  in  swift  motion. 

6.  He  has  several  times  and  first  on  awaking  seen  the  door  open  and 
a  procession  of  white-robed  veiled  figures  enter.  They  did  not  fade 
until  he  arose  and  lit  the  gas.  These  w-ere  seen  wdth  his  eyes  open  or 
shut,  and  he  could  not  double  them  by  causing  himself  to  squint  by 
pressure  on  one  eye. 

At  one  time  for  two  years  he  had  frequent  vertigo  without  loss  of  dis- 
tinctness of  hearing.  It  was  apparently  of  lithsemic  origin,  and  was 
relieved  by  careful  correction  of  diet.  Of  late  he  has  some  acidity  of 
stomach  after  an  attack,  and  is  often  able  to  cut  off  a  second  headache 
by  a  saline  cathartic.  As  the  near  use  of  his  eyes  seemed  to  be  the 
main  cause  of  trouble,  and  to  be  competent  to  bring  about  the  series  of 
congestive  conditions  which  evolved  the  phenomena  I  have  described, 


KINNICUTT,   ATROPHY   OF   THE    GASTRIC  TUBULES.  419 

I  asked  Dr.  William  Thomson  to  reexamine  his  eyes.  Briefly,  he  had 
no  insufficiency,  but  there  was  in  the  right  eye  hypermetropic  astigmatism 
of  three-quarters  of  a  dioptric  axis  at  75°,  and  in  the  left  myopia  of  one 
dioptric  and  hypermetropic  astigmatism  of  2.5  dioptric  axis  at  100°. 
There  was  no  marked  gain  from  any  treatment,  and  I  have  not  seen 
the  case  for  some  time. 

Our  present  state  of  knowledge,  or  want  of  knowledge,  makes  comment 
difficult  as  regards  these  cases.  Why  should  the  zigzag  lines  or  the 
Catherine  wheel  be  so  common,  and  how  shall  we  explain  why  in  rare 
cases  the  storehouse  of  memory  sets  free  for  visual  projection  strange 
figures  long  unremembered  ?  The  phenomena  are  not  uncommon  in 
disease,  but  their  association  as  part  of  the  complex  symptom,  hemi- 
crania,  is  undescribed.  The  connection  of  epilepsy  and  prodromic 
visions  I  have  often  seen.  Finally,  one  is  tempted  to  ask  if  some  ghost 
stories  may  not  arise  out  of  these  rare  examples  of  headaches  preceded 
by  hallucinations. 


ATROPHY  OF  THE  GASTEIC  TUBULES : 
ITS  RELATIONS  TO  PERNICIOUS  ANEMIA. 

By  F.  P.  Kijjnictjtt,  M.D., 

PHYSICIAN  TO  ST.  LUKE'S  HOSPITAL  AND  THE  NEW  YORK  CANCER  HOSPITAL,  NEW  YORK. 

As  early  as  1860  Dr.  Austin  Flint1  suggested  the  probable  depend- 
ence of  the  group  of  cases  known  as  pernicious  ansemia  upon  degen- 
erative disease  of  the  gastric  tubules,  and  ventured  to  predict  that 
eventually  this  opinion  would  be  corroborated.  Investigations  of 
morbid  changes  in  the  mucous  membrane  of  the  stomach  had  previously 
been  reported  in  England  by  Drs.  Hanfield  Jones,2  Wilson  Fox,3  and 
Habershon,4  and  in  Germany  particularly  by  Dr.  F.  Schapfer.5  They 
did  not  consider,  however,  the  marked  and  different  changes  found  with 
reference  to  the  anatomical  characteristics  of  any  particular  disease  or 
diseases. 

In  1865  a  memoir  by  Dr.  Samuel  Fenwick6  was  published  on  the 
"  Morbid  Changes  in  the  Stomach  and  Intestinal  Villi  present  in  Persons 
who  have  died  of  Cancer."    The  histological  changes  found  by  him  in 

1  Degenerative  Disease  of  the  Glandular  tubuli  of  the  Stomach,  American  Medical  Times,  September 
15,  1860. 

2  Observations  of  Morbid  Changes  in  the  Mucous  Membranes  of  the  Stomach,  Medico-Chirurgical 
Transactions,  vol-  xxxvii.,  1854. 

3  Contributions  to  the  Pathology  of  the  Glandular  Structures  of  tho  Stomach,  Medico-Chirurgical 
Transactions,  vol.  lxi.,  1858. 

4  Cases  Illustrating  the  Pathology  of  the  Stomach,  Guy's  Hospital  Reports,  Series  III.,  vol.  i  ,  L869- 
1855. 

5  Virchow's  Archiv,  vol.  vii.  0  Medico-Chirurgical  Transactions,  vol.  xlviii. 


420     KINNICUTT,   ATROPHY  OF    THE   GASTRIC  TUBULES. 

many  of  his  cases  were  very  similar  to  those  described  by  the  previously 
mentioned  observers,  viz.,  disappearance  of  the  cells  in  the  gastric  tubules, 
granulo-fatty  degeneration  and  atrophy,  and  an  increased  formation  of 
connective  tissue.  He  also  noted  a  marked  thinning  of  the  mucous 
membrane  and  decrease  of  its  weight.  The  above  changes  were  more 
marked  in  those  patients  who  had  suffered  from  cancer  of  the  breast. 
He  suggested  that  these  alterations  in  the  secretory  structures  of  the 
stomach  offered  a  possible  explanation  of  the  anaemia  which  accompanies 
malignant  disease. 

In  1877  four  cases  of  pernicious  anaemia  were  reported  by  Dr.  Fen- 
wick1  (including  one  previously  reported  by  Dr.  Hanfield  Jones),  in 
which  marked  and  very  general  atrophy  of  the  gastric  tubules  was 
found.  The  only  other  cases  presenting  the  clinical  picture  of  progres- 
sive pernicious  anaemia  and  associated  with  atrophy  of  the  gastric  mucous 
membrane,  which  I  have  been  able  to  find  recorded,  are  two  by  Nolen,2 
one  by  Quincke,3  one  by  Brabazon,4  one  by  Henry  and  Osier.5  Koth- 
nagel  has  reported  a  case  of  cirrhosis  of  the  stomach  with  the  clinical 
symptoms  of  pernicious  anaemia.6  In  some  of  these  cases  the  histo- 
logical investigations  lack  desirable  completeness.  During  the  past  two 
years  three  "cases  of  pernicious  anaemia  have  come  under  the  author's 
observation  in  the  wards  of  St.  Luke's  Hospital.  The  patients  were 
carefully  observed  over  very  considerable  periods  of  time,  and  in  two  of 
the  cases  autopsies  were  obtained. 

The  histories  well  illustrate  the  group  of  symptoms  which  have  come 
to  be  regarded  as  pathognomonic  of  pernicious  anaemia,  and  the  histo- 
logical investigations  would  seem  to  confirm  the  opinion  which  has  been 
expressed  by  several  observers,  that  "  a  primary  degeneration  and 
atrophy  of  the  gastric  tubules  occurs,"  and  that  extensive  destruction 
of  the  secretory  structures  of  the  stomach  may  be  regarded  as  causal  in 
a  certain  number  of  cases  of  pernicious  anaemia. 

Case  I. — J.  T.,  male,  aged  forty-six,  carpenter.  Admitted  to  St. 
Luke's  Hospital  April  9,  1886.  Family  history  negative.  The  patient 
stated  that  he  had  been  a  moderate  drinker ;  denied  venereal  disease. 
For  the  past  five  or  six  years  his  appetite  had  been  poor,  and  he  had 
suffered  from  constipation.  He  had  been  troubled  with  vomiting 
"  off  and  on"  during  this  period,  and  thought  that  he  had  gradually  lost 
flesh.  For  the  last  two  years  he  had  had  much  headache,  and  occasional 
attacks  of  loss  or  marked  dimness  of  eyesight.  Six  months  ago  he  began 
to  be  troubled  with  breathlessness  on  slight  exertion,  his  feet  became 
swollen,  and  he  was  obliged  to  give  up  work.  The  dyspnoea  persisted, 
but  the  oedema  gradually  disappeared,  and  he  was  able  temporarily  to 

1  Fenwick :  London  Lancet,  1877,  vol.  ii. 

2  Centralblatt  f.  d.  medicinische  Wissenschaften,  Bd.  xx. 

3  Quincke  :  Volkmann's  Saraml.  klin.  Vortrage,  No.  100  (Case  b). 

4  Brabazon  :  British  Medical  Journal,  1878,  July  27  (without  microscopical  examination). 

5  Henry  and  Osier  ;  American  Journal  of  the  Medical  Sciences,  April,  1886. 
o  Nothnagel :  Deutsches  Arch.  f.  kl.  Med.,  Bd.  24,  p.  353. 


KINNICUTT,  ATROPHY   OF   THE   GASTRIC   TUBULES.  421 


return  to  work.  For  the  past  month  he  has  again  been  worse  ;  he  has 
been  very  weak  and  confined  to  his  bed  the  greater  portion  of  the  time. 

On  admission  to  the  hospital  the  patient  was  very  weak,  and  suffered 
from  breath lessness  and  palpitation  on  the  slightest  exertion.  There  was 
extreme  pallor  of  the  skin  of  the  trunk  and  extremities,  with  the  peculiar 
lemon-tint  of  the  skin  of  the  face  which  obtains  very  constantly  in  perni- 
cious anaemia.  The  ocular  conjunctiva  was  of  the  latter  hue,  the  palpebral 
conjunctiva  milky  white,  apparently  bloodless,  as  were  the  other  visible 
mucous  membranes.  There  was  slight  oedema  about  the  ankles  and  puffi- 
ness  about  the  eyes,  and  slight  oedema  of  the  skin  of  the  entire  body. 
The  heart's  apex  was  in  the  fifth  space,  within  the  mammillary  line ;  a 
soft  systolic  murmur  was  heard  over  the  mitral  area,  and  a  similar  one 
over  the  pulmonary  area.  There  was  no  evidence  of  pulmonary  disease, 
and  the  areas  of  hepatic  and  splenic  dulness  were  apparently  normal. 
There  was  a  slightly  enlarged  gland  at  the  angle  of  the  jaw  on  each  side, 
sensitive  on  pressure.  The  superficial  glands  elsewhere  were  not  enlarged. 
There  was  an  absence  of  external  evidence  of  syphilis.  The  patient  was 
emaciated ;  the  abdominal  walls,  however,  contained  a  fair  amount  of  fat. 
The  pulse  was  84,  and  was  soft  and  compressible  ;  there  was  no  appreci- 
able thickening  of  the  walls  of  the  superficial  arteries.  The  temperature 
(in  mouth)  was  99.2°.  The  urine  was  free  from  albumen,  sugar,  and  bile 
pigment.  Specific  gravity  1.020.  Microscopic  examination  negative. 
Examination  of  the  blood,  April  17th :  Number  of  red  globules  per  cubic 
millimetre  2,225,000  (5,000.000  normal),  hsemic  unit  therefore  44.5. 
Proportion  of  white  to  red  globules  1  : 130.  Percentage  of  haemoglobin 
(estimated  by  Gower's  hsemoglobinometer)  35.  The  red  blood  globules 
were  round,  oval,  and  pear-shaped,  and  many  were  much  larger  than 
normal.  Microcytes  were  present  in  considerable  number ;  only  an  occa- 
sional Schultze's  granule  mass  was  seen.  The  patient  had  two  rather  pro- 
fuse hemorrhages  from  the  bowels  on  the  day  of  admission.  Arsenic, 
iron,  and  daily  inhalations  of  oxygen,  with  a  milk  diet,  were  ordered. 

April  28th.  The  patient's  condition  is  very  much  the  same  as  on 
admission.  Examination  of  the  blood :  Number  of  red  blood  globules 
per  cubic  millimetre  2.451.000,  hsemic  unit  49.  Proportion  of  white  to 
red  1  : 123.    Percentage  of  haemoglobin  40. 

May  2UL  Has  steadily  grown  worse.  The  enlargement  of  the  glands 
at  the  angle  of  the  jaw  has  disappeared.  There  is  distressing  palpita- 
tion and  dyspnoea  on  slight  exertion.  The  cardiac  murmurs  have 
increased  in  intensity,  and  a  loud  systolic  murmur  is  heard  over  the 
vessels  of  the  neck.  The  first  sound  of  the  heart  is  markedly  feeble, 
pulse  102.  Temperature  normal.  The  daily  average  excretion  of  urine 
is  56  ounces.  (The  patient  takes  nearly  two  quarts  of  milk  daily.) 
Occasionally  a  trace  of  albumen  is  present,  but  no  casts  have  been  found 
at  any  time.  The  daily  average  excretion  of  urea  is  about  seven  grains 
to  the  ounce.  Examination  of  blood :  Number  of  red  globules  per 
cubic  millimetre  1,067,000,  hsemic  unit  21.3.  Proportion  of  white  to 
red,  1:107.  Ophthalmoscopic  examination  by  Dr.  Edward  Loring: 
The  fundus  of  the  left  eye  is  hazy  and  indistinct,  the  nerve  is  very  pale, 
the  capillary  circulation  is  almost  nil ;  it  has  the  whiteness  of  atrophy, 
but  appears  more  woolly.  The  arteries  are  reduced  in  size,  and  are 
almost  white,  with  broad  white  reflex.  The  veins  are  increased  in  size, 
and  are  tortuous,  carrying  their  size  far  into  the  retina  and  tapering  at 
the  disk.    The  arteries  and  veins  are  of  nearly  the  same  color  on  the 


422     KINNICUTT,  ATROPHY   OF   THE    GASTRIC  TUBULES. 

disk ;  the  veins  are  much  darker  in  the  retina.  There  is  no  pulsation 
in  either  veins  or  arteries.  There  is  pulsation  in  both  veins  and  arteries 
on  pressure.  There  is  no  general  retinitis  or  neuro-retinitis.  There  is 
an  absence  of  white  plaques.  There  is  no  swelling  of  the  disk.  The 
fundus  of  the  eye  presents  the  same  appearance  of  pallor  as  the  face. 
The  right  eye  is  the  same  as  the  left. 

June  19.  The  patient's  condition  is  worse.  There  is  gradually  in- 
creasing oedema  of  the  lower  extremities  and  of  the  face.  Pulse  124 
and  exceedingly  weak ;  temperature,  lOOf  °.  Complains  of  a  "  woolly  " 
feeling  in  the  ears  and  of  dimness  of  eyesight.  Examination  of  blood  : 
number  of  red  blood  globules  per  cubic  millimetre  948,881,  haemic 
unit  18.9.  Proportion  of  white  to  red  1  : 124.  Percentage  of  haemo- 
globin 11.5  (the  extremely  pale  tint  of  the  blood  may  have  vitiated  the 
correctness  of  the  color  test).  The  arsenic,  the  dose  of  which  had  been 
gradually  increased,  and  the  iron  were  discontinued,  and  caffeine,  digi- 
talis, and  whiskey  (three  ounces  daily)  were  ordered. 

27th.  There  has  been  marked  improvement  in  the  patient's  condition 
since  the  last  note.  The  oedema  has,  to  a  great  extent,  disappeared,  the 
pulse  is  markedly  stronger  and  96,  temperature  normal.  The  patient 
expresses  himself  as  feeling  "  a  hundred  per  cent,  better."  Exami- 
nation of  the  blood  :  number  of  red  globules  per  cubic  millimetre 
1,133,750 ;  haemic  unit  22.6.  Proportion  of  white  to  red,  1  :  203.  Per- 
centage of  haemoglobin  20.  Microscopic  examination  shows  similar 
forms  of  globules  to  those  previously  noted. 

July  7.  The  improvement  has  been  maintained.  The  patient  is  again 
taking  arsenic  and  to-day  enemata  of  defibrinated  beef  blood,  eight 
ounces  daily,  are  ordered  in  addition.  Examination  of  blood:  number 
of  red  blood  globules  per  cubic  millimetre  2,163,400 ;  haemic  unit,  43.2. 
Proportion  of  white  to  red,  311  red  counted,  no  white  seen.  Percentage 
of  haemoglobin  39. 

22d.  Has  still  further  improved.  Is  able  to  be  up  and  about  and 
has  been  absent  from  hospital  on  leave  on  several  occasions.  The  mucous 
membranes  are  not  as  absolutely  bloodless  as  has  been  the  case  hitherto. 
Temperature  99.2°.  There  has  been  no  increase  in  the  patient's  weight. 
The  daily  percentage  of  excretion  of  urea  has  slightly  increased  since 
the  administration  of  the  beef  blood ;  the  amount  of  urine  voided  has 
maintained  its  former  average.  Examination  of  blood:  number  of  red 
globules  per  cubic  millimetre  2,072,525;  haemic  unit,  41.4;  percentage 
of  haemoglobin  40.  The  majority  of  the  red  globules  are  certainly 
larger  than  normal  and  many  are  pear-shaped  and  oval. 

August  8.  The  patient  is  again  worse.  There  is  again  great  weakness 
and  much  oedema.  Temperature  103°.  Examination  of  blood :  red 
globules  per  cubic  millimetre  1,161,400;  haemic  unit  23.2;  proportion 
of  white  to  red  1  :  288 ;  percentage  of  haemoglobin  26. 

September  J+.  There  is  little  or  no  change  in  the  patient's  condition. 
Temperature  normal.  Examination  of  blood  :  number  of  red  globules 
per  cubic  millimetre  1,328,450 ;  haemic  unit  26.5 ;  proportion  of  white 
to  red,  254  red  counted,  no  white  seen  ;  percentage  of  haemoglobin  33. 

18th.  The  patient's  condition  remains  the  same.  Temperature  99.3°. 
Examination  of  blood  :  number  of  red  globules  per  cubic  millimetre 
1,351,687  ;  haemic  unit  27  ;  proportion  of  white  to  red,  320  red  counted, 
no  white  seen ;  percentage  of  haemoglobin  30.    On  this  date  the  patient 


KINNICUTT,  ATROPHY   OF   THE  GASTRIC 


TUBULES. 


423 


was  discharged  from  hospital  with  the  understanding  that  he  should 
still  remain  under  observation. 

He  was  seen  from  time  to  time  during  the  succeeding  three  months. 
He  was  able  during  the  greater  portion  of  this  period  to  be  up  and  to 
walk  moderate  distances  without  much  distress.  During  the  early  part 
of  December  he  began  to  be  troubled  with  diarrhoea,  the  oedema  again 
became  troublesome,  he  rapidly  grew  weaker,  there  was  much  dyspnoea 
and  palpitation,  and  on  December  21st,  he  was  readmitted  to  the  hospital. 

On  this  date  the  results  of  physical  examination  were  much  the  same 
as  on  the  patient's  first  admission  to  the  hospital  except  that  the  emacia- 
tion was  greater.  The  murmurs  heard  over  the  cardiac  area  and  over 
the  vessels  of  the  neck  were  more  intense  in  character,  there  was  moder- 
ate oedema  of  the  lower  extremities  and  of  the  whole  integument.  The 
patient  was  very  weak,  pulse  90,  temperature  normal.  The  urine  was 
free  from  albumen,  sugar,  and  bile  pigment,  specific  gravity  1.011,  acid. 

Ophthalmoscopic  examination  by  Dr.  Loring.  The  blood  in  the  arteries 
is  very  light  colored,  and  on  the  disk  of  a  milky  appearance.  The  reflex 
on  the  veins  is  broad  and  of  a  white  color,  as  if  the  walls  of  the  vessels 
were  affected.  There  are  some  small  decolorized  hemorrhages  or  exuda- 
tions. There  is  a  marked  arterial  pulse  on  pressure.  The  upper  artery 
becomes  blanched  on  pressure.  The  vessels  in  the  retina  have  a  waxy 
appearance,  possibly  due  to  changes  in  their  walls.  Examination  of 
blood :  number  of  red  globules  per  cubic  millimetre  930,000  ;  hsemic 
unit  18.6  ;  proportion  of  white  to  red  1  :  107  ;  percentage  of  haemo- 
globin 10. 

From  this  date  the  patient  gradually  failed,  effusion  gradually  oc- 
curred in  the  pleural  cavities,  there  was  vomiting  from  time  to  time  of 
matter  of  the  color  of  chocolate,  and  death  finally  occurred  on  January 
19th.  Four  days  previous  to  death  a  distinct  icteroid  tint  of  the  con- 
junctivae and  skin  was  developed.  The  daily  average  excretion  of  urea 
was  almost  indentical  with  that  noted  on  the  patient's  previous  stay  in 
hospital.  Throughout  the  whole  period  of  observation  there  was  marked 
anorexia,  but  little  epigastric  distress  or  vomiting  after  the  ingestion  of 
food,  until  the  last  days  of  life.  Milk  constituted  the  principal  article 
of  diet. 

It  was  ascertained  from  the  patient's  friends,  after  his  death,  that  he 
had  been  a  hard  drinker  for  many  years. 

The  autopsies  and  histological  investigations  in  both  cases  were  made 
by  Dr.  Frank  Ferguson,  the  pathologist  of  the  hospital,  and  to  him  the 
author  is  greatly  indebted  for  the  time  and  labor  given  to  the  task. 

Autopsy  twenty-eight  hours  after  death.  The  body  was  extremely 
emaciated,  and  its  surface  very  anaemic,  and  slightly  jaundiced.  There 
was  no  oedema.  Rigor  mortis  was  present.  The  muscular  tissue  of  the 
abdominal  wall  was  amemic  and  flabby.  The  peritoneum  was  pale,  but 
otherwise  normal. 

Pleural  cavities.  There  were  twenty-four  ounces  of  straw-colored  serum 
in  each,  and  there  were  old  adhesions  at  each  apex. 

Heart.  There  were  eight  ounces  of  straw-colored  serum  in  the  pericar- 
dium. The  heart  was  slightly  increased  in  size.  Its  muscular  tissue  was 
flabby  and  anaemic.  The  heart  muscle  contained  a  great  deal  of  fat,  The 
ventricles  were  dilated  ;  the  auricles  were  also  dilated,  but  to  a  less  degree  : 


424     KINNICUTT,  ATROPHY    OF   THE   GASTRIC  TUBULES. 

all  the  cavities  contained  partially  decolorized  clots.  The  valves  were 
normal.    The  coronary  arteries  were  normal. 

Lungs  were  intensely  (edematous.  The  fluid  oozing  from  the  cut 
surface  was  stained  with  bile.    They  were  otherwise  normal. 

Spleen  was  normal  in  size  and  firm  in  consistency,  but  very  anaemic. 

Kidneys  were  normal  in  size,  and  firm  in  consistency.  The  capsules 
wTere  not  adherent,  the  surfaces  were  smooth,  the  markings  were  not 
distinct.    They  were  anaemic.  1 

Suprarenal  capsules  were  normal  in  size ;  the  cortex  of  each  contained 
a  great  deal  of  fat.    The  medullary  portion  appeared  normal. 

Stomach  was  moderately  distended  with  gas,  and  it  contained  a  small 
amount  of  dark-colored  fluid.  It  was  normal  in  size,  and  the  calibre  of 
the  pylorus  was  normal.  The  wall  of  the  stomach,  where  it  was  in  contact 
with  its  fluid  contents,  appeared  thinner  than  normal.  The  veins  beneath 
the  mucous  membrane  wTere  unusually  prominent.  The  mucous  mem- 
brane in  the  neighborhood  of  the  pylorus  was  slightly  thicker  than  at 
the  fundus.  The  surface  of  the  mucous  membrane  was  smooth,  and  the 
stomach  wall  throughout  was  very  anaemic.   The  oesophagus  was  normal. 

Pancreas  was  anaemic.  It  was  normal  in  size ;  it  was  slightly  stained 
with  bile. 

Intestine.  The  mucous  membrane  of  the  small  intestine  was  covered 
with  mucus.  It  was  anaemic  and  pigmented.  The  large  intestine  was 
filled  with  soft  feces  of  a  metallic  lustre. 

Thoracic  duct  was  normal. 

Liver  was  small,  weighing  two  and  three-quarters  pounds.  It  was  gen- 
erally stained  with  bile.  There  was  much  fat  arranged  around  the  peri- 
phery of  the  lobules.  It  was  very  anaemic.  The  gall-bladder  contained 
mucus.  Its  duct  was  impacted  with  a  black  calculus,  one  inch  in  diameter. 
There  w7ere  other  smaller  calculi  in  the  common  duct,  but  its  muscular 
wall  and  mucous  membrane  appeared  normal.  The  orifice  of  the  common 
duct  was  pervious. 

Head  and  brain.  The  calvaria  were  normal.  The  brain  was  intensely 
anaemic.  There  was  slight  atrophy  of  the  convolutions  over  the  vertex  of 
both  hemispheres.  The  Pineal  gland  was  very  small.  There  was  an 
absence  of  the  soft  commissure. 

Sympathetic  system.  The  semilunar  ganglia  were  normal  in  appearance. 

Marrow.  There  was  no  difference  in  the  color  and  consistency  of  the 
marrow  of  the  long  and  short  bones.  In  both  locations  it  closely  resem- 
bled the  normal  marrow  of  the  short  bones.  There  was  no  fat  in  the 
marrow  of  the  long  bones. 

Histological  Examination. — Heart.  Small  portions  of  the  muscular 
wall  of  the  auricles  were  teased,  and  considerable  fat  in  small  globules 
was  seen  in  the  cardiac  cells.  The  auricles  showed  an  equal  degree  of  fatty 
degeneration.  In  fresh  sections  of  the  wall  of  the  left  ventricle,  whole 
areas  of  the  cardiac  muscle  were  seen  in  the  condition  of  fatty  degenera- 
tion. Everywhere  the  transverse  striae  were  absent,  and  the  cardiac  cells 
were  granular,  and  many  of  these  appeared  like  small  tubes  filled  with 
fat  granules.  There  was  an  equal  degree  of  fatty  degeneration  in  the 
walls  of  both  ventricles,  and  it  was  more  marked  than  in  the  auricles. 

Kidneys.  There  was  a  great  deal  of  fat  in  the  convoluted  tubes  of  the 
kidney.  The  epithelium  was  everywhere  swollen,  granular,  and  fatty. 
The  fatty  degeneration  was  especially  well  marked  in  the  cortex.  There 


KINNICUTT,   ATROPHY   OF   THE    GASTRIC  TUBULES.  425 


was  no  increase  in  the  fibrous  tissue,  but  numerous  small,  round  cells,  of 
inflammatory  origin  were  seeu  in  the  stroma  of  the  organs. 

Adrenales.  There  was  much  fat  in  circumscribed  areas  in  the  cortex  of 
each  suprarenal  capsule.  In  some  places  the  proper  cortex  of  the  cap- 
sules was  completely  replaced  by  fat. 

Pancreas.  There  was  a  slight  increase  in  the  fibrous  tissue  of  the  pan- 
creas. There  was  considerable  fat  arranged  as  follows:  1.  A  very  con- 
siderable quantity  between  the  aciui,  in  the  planes  of  the  fibrous  tissue. 
2.  There  were  large  globules  of  fat  seen  by  the  unaided  eye  within  the 
acini.  This  fat  in  the  recent  state  was  of  brownish  color,  and  the  globules 
showed  many  lines  of  constriction,  as  in  the  process  of  division  and  sub- 
division. 3.  The  cells  of  the  gland  contained  very  fine  granules  of  fat. 
The  cells  were  swollen. 

Liver.  There  was  a  great  deal  of  fat  in  the  liver.  The  fat  was  more 
abundant  at  the  periphery  of  the  lobules,  but  everywhere  the  hepatic 
cells  contained  a  large  number  of  fat  granules.  There  was  brown  pig- 
ment in  the  cells  in  the  centres  of  the  acini.  There  was  bile  pigmeut  in 
all  the  lobules.  The  large  bile-ducts,  which  were  easily  distinguished 
under  the  microscope,  were  normal. 

Ganglia  of  the  sympathetic.  The  ganglion  cells  were  deeply  pigmented  ; 
in  other  respects  the  cells  were  normal.  There  was  no  change  noticed  in 
the  nerve  fibres  or  fibrous  tissue. 

Stomach.  The  walls  of  the  stomach,  including  all  its  coats,  appeared 
so  natural  that  no  effort  was  made  to  measure  their  thickness  in  the  fresh 
state.  Any  measurements  of  either  the  mucous  membrane  or  muscular 
Avail  of  the  organ,  after  stretching  on  cork  and  hardening  in  alcohol,  can 
only  be  regarded  as  useless,  since  the  thickness  materially  depends  on 
the  degree  of  tension  to  which  the  organ  is  submitted  in  thus  preparing 
it  for  microscopical  examination.  Numerous  sections  were  made  of  the 
stomach  wall  in  the  neighborhood  of  the  pylorus  ;  at  the  distance  of  two, 
four,  six,  and  ten  centimetres  above  the  pylorus,  along  the  greater  and 
lesser  curvatures;  of  the  anterior  and  posterior  walls,  in  the  midzone  of 
the  stomach ;  of  the  different  parts  of  the  fundus  not  in  contact  with  the 
fluid,  and  in  the  neighborhood  of  the  oesophagus,  and  the  following  con- 
ditions of  the  mucous  membrane  were  found  in  all  the  sections  examined. 
In  extensive  areas  of  the  mucosa  not  a  trace  of  the  gastric  tubules  could 
be  seen.  In  places,  however,  the  most  superficial  parts  of  the  gastric- 
tubes,  lined  with  cylindrical  epithelium,  could  be  distinguished.  The 
deeper  portions  of  the  tubules  could  nowhere  be  made  out.  In  the  recent 
state  the  cells  lining  these  remnants  of  tubules  were  granular  and  fatty. 
There  was  a  large  amount  of  fat  in  the  stroma  of  the  mucous  membrane 
in  very  fine  granules.  There  was  considerable  hyaline  material,  resembling 
the  hyaline  casts  of  the  renal  tubes.  This  material  was  seen  in  places  in 
droplets,  in  places  having,  apparently,  the  shape  of  the  tubes.  Osmic 
acid  did  not  stain  it  readily,  and  ether  did  not  dissolve  it.  It  was  slowly 
stained  by  Bismarck-brown  and  the  aniline  colors.  It  was  dissolved  by  the 
prolonged  action  of  ninety-five  per  cent,  alcohol.  Numerous  cells  were 
seen  near  the  surface  of  the  mucosa,  which  were  irregular  in  shape,  and 
of  the  same  size  as  the  cells  which  lined  the  deeper  portions  of  the  gastric 
tubules.  Some  of  these  had  undergone  hyaline  degeneration.  Through- 
out the  mucosa  everywhere  were  large  numbers  of  small  triangular  bodies, 
slightly  larger  than  pus  cells,  without  nuclei.  These  were  isolated  in 
places,  but  were  more  frequently  found  in  groups.    They  behaved  to  re- 


426     KINNICUTT,  ATROPHY  OF   THE    GASTRIC  TUBULES. 

agents  much  the  same  as  the  hyaline  material  already  noticed.  The 
fibrous  tissue  of  the  mucosa  was  not  increased. 

In  addition  to  the  elements  already  noticed,  the  mucous  membrane 
was  everywhere  infiltrated  with  the  small  round  cells  so  common  in  in- 
flammatory processes. 

The  only  difference  noticed  between  the  sections  from  the  various 
regions  of  the  stomach  was  that  the  remnants  of  a  greater  number  of 
tubes  were  seen  in  the  pyloric  zone  ;  but  nowhere  were  the  secreting  struc- 
tures proper  to  the  stomach  noticed.  The  muscularis  mucosae  appeared 
normal.  There  was  a  very  moderate  amount  of  fat  in  the  submucosa. 
The  submucosa  otherwise  appeared  normal.  The  muscular  wall  of  the 
stomach  appeared  normal.    The  vessels  were  normal. 

Intestines.  Sections  of  the  duodenum,  jejunum,  ileum,  and  colon  were 
examined,  aud  no  special  change  was  noticed. 

Marrow.  There  was  no  fat  in  the  marrow  of  the  short  bones.  There 
were  seen  in  it  all  the  other  elements  normally  found  in  this  location,  and 
also  numerous  small  cells  without  nuclei,  spheroidal  in  shape,  and  paler 
than  red  corpuscles.  Nucleated  red  corpuscles  were  not  present.  A  few 
of  the  Charcot-Neumann  crystals  were  present.  The  bone  framework 
supporting  the  marrow  was  normal.  The  marrow  of  the  long  bones  con- 
tained no  fat.  Small,  round,  colored  corpuscles,  similar  to  those  found 
in  the  marrow  of  the  short  bones,  were  noticed.  Also  several  Charcot- 
Neumann  crystals. 

The  tissues  of  the  eye  were  carefully  examined,  and  Dr.  Loring  has 
kindly  sent  the  following  report : 

Beyond  a  certain  dimness  of  the  nervous  elements,  they  appeared 
normal.  There  wTas  no  increase  of  the  connective  tissue  either  in  the 
nerve  or  retina.  The  vessels  were  normal,  arteries  as  well  as  veins 
showing  neither  thickening  nor  degeneration  of  their  walls.  They  con- 
tained^ however,  very  little,  if  any,  blood.  No  red  blood-cells  were  seen 
in  either  the  retina,  the  choroid,  or  ciliary  vessels  around  the  nerve. 
The  choroid  and  sclera  appeared  normal. 

Resume. —  Clinical.  A  history  of  a  possibly  excessive  use  of  alcohol 
for  many  years,  of  anorexia  and  gastric  disturbance  for  five  or  six 
years,  of  marked  anaemia,  and  failing  health  and  strength,  and  of  ema- 
ciation during  the  six  months  previous  to  the  patient's  admission  to  the 
hospital.  The  occasional  occurrence  of  hemorrhages,  the  presence  of 
an  irregular  temperature  curve,  gradually  increasing  emaciation  and 
prostration,  with  brief  periods  of  improvement  while  the  patient  was 
under  observation.  Red  blood-globules  finally  reduced  to  930,000  per 
cubic  millimetre,  the  relative  percentage  of  haemoglobin  remaining 
normal.  Megalocytes  and  poikilocytes  in  the  blood  in  large  numbers, 
microcytes  in  considerable  number.  Death  by  asthenia,  nine  months 
after  admission  to  the  hospital. 

Anatomical.  Extreme  emaciation  and  anaemia,  fatty  changes  in  all 
the  viscera,  an  absence  of  fat  in  the  marrow  of  the  long  bones,  almost 
complete  destruction  of  the  gastric  tubules. 

Case  II. — C.  M.,  aged  thirty-seven,  salesman,  was  admitted  to  St. 
Luke's  Hospital  July  14,  1886.    The  patient's  family  history  was  nega- 


KINNICUTT,  ATEOPHY   OF   THE    GASTRIC   TUBULES.  427 


tive.  With  the  exception  of  an  attack  of  acute  articular  rheumatism  in 
1874  and  two  attacks  of  gonorrhoea,  the  last  one  in  1883,  the  patient 
stated  that  he  had  enjoyed  excellent  health  until  about  eight  months 
ago.  He  denied  venereal  disease,  other  than  that  mentioned  above. 
Periodically,  he  had  used  alcohol  in  great  excess.  His  weight,  in 
December,  1885,  was  190  pounds.  Four  months  ago,  he  began  to  lose 
flesh  and  his  appetite  and  strength  became  impaired.  At  this  time  he 
was  in  the  habit  of  taking  alcohol,  in  one  form  or  another,  before  break- 
fast. The  anorexia  increased,  until  two  months  later  he  was  unable  to 
take  any  solid  food  ;  forced  attempts  were  followed  by  vomiting.  Grad- 
ually great  breathlessness  and  palpitation  on  slight  exertion  were 
developed. 

On  admission  to  the  hospital,  the  patient  was  much  emaciated  and 
w7eak.  His  weight  was  131  pounds.  There  were  marked  dyspnoea  and 
palpitation  on  slight  exertion.  The  skin  was  extremely  pallid  as  were  the 
visible  mucous  membranes.  The  heart's  apex  was  in  the  fifth  space, 
within  the  mammillary  line ;  there  was  an  absence  of  murmurs.  There 
was  no  evidence  of  pulmonary  disease.  The  areas  of  hepatic  and  splenic 
dulness  were  apparently  normal.  There  was  slight  enlargement  of  the  in- 
guinal and  post-cervical  glands. ,  There  was  moderate  sensitiveness  on 
pressure  over  the  epigastric  region.  The  pulse  was  90,  short  and  com- 
pressible. There  was  no  evident  thickening  of  the  walls  of  the  superficial 
arteries.  There  were  no  cicatrices  on  the  glans  penis  or  in  the  groins.  The 
urine  was  free  from  albumen,  sugar,  and  bile  pigment — specific  gravity 
1.022. 

An  examination  of  the  blood  was  not  made  until  August  14th.  On 
this  date  the  number  of  red  blood- globules  per  cubic  millimetre  was 
1,862,325,  hsemic  unit,  therefore,  35.2;  proportion  of  white  to  red 
globules,  233  red  counted,  no  white  seen  ;  percentage  of  haemoglobin 
30.  The  red  globules  were  round,  oval,  and  pear  shaped.  Microcytes 
were  present  in  considerable  numbers. 

August  16.  The  area  of  splenic  dulness  reaches,  anteriorly,  the 
anterior  axillary  line,  indicating  apparently  an  increase  in  size  of  the 
spleen  since  admission.  The  enlargement  of  the  inguinal  and  post- 
cervical  glands  remains  unchanged. 

24-th.  Examination  of  the  blood:  Number  of  red  blood-globules  per 
cubic  millimetre  1,461,825,  hsemic  unit  29.2,  proportion  of  white  to  red, 
329  red  counted,  no  white  seen. 

Poikilocytes  are  very  numerous,  megalocytes  and  microcytes  are 
present  in  considerable  numbers. 

September  14.  The  patient's  condition  has  steadily  grown  worse  since 
admission.  The  temperature  is  normal.  Examination  of  blood  :  Num- 
ber of  red  globules  per  cubic  millimetre  1,020,950,  hsemic  unit  20.4  ; 
proportion  of  white  to  red  not  increased.   Percentage  of  haemoglobin  25. 

28th.  Ophthalmoscopic  examination  by  Dr.  Loring.  The  capillary 
circulation  of  the  disk  is  very  much  reduced.  The  color  of  the  blood 
in  the  veins  is  very  much  lighter  than  normal,  corresponding  in  appear- 
ance to  arterial  blood  in  the  normal  eye.  The  blood  in  the  arteries  is 
lighter  than  normal.  The  disk  looks  atrophic.  There  are  hemorrhages 
in  the  upper  ascending  vein  and  below  the  region  of  the  macula,  also 
capillary  hemorrhages  near  some  of  the  veins,  and  here  and  there  in 
spots  in  the  upper  and  outer  quadrant  of  the  field.  The  external 
borders  of  both  veins  and  arteries  are  not  clearly  marked,  the  edge 


428     KINNICUTT,  ATROPHY   OF   THE   GASTRIC  TUBULES. 


being  ragged.  There  is  little  or  no  oedema  anywhere,  and  there  is  an 
absence  of  swelling  of  the  retina. 

In  spite  of  every  therapeutic  measure,  the  patient  continued  to  fail. 
No  new  symptoms  were  developed,  those  present  on  admission  simply 
increased  in  intensity.  There  was  complete  anorexia  and  the  emaciation 
gradually  increased.  Physical  examination  continued  to  give  the  same 
nearly  negative  results,  with  the  exception  of  the  increase  in  the  size  of 
the  spleen  previously  noted.  The  temperature  was  above  normal  during 
a  portion  of  the  month  of  August,  the  curve  being  very  irregular ;  dur- 
ing the  other  periods  of  the  patient's  illness,  there  was  apyrexia.  The 
average  daily  excretion  of  urine  was  thirty- six  and  one-half  ounces,  the 
average  daily  excretion  of  urea  was  normal.  Owing  to  unavoidable 
circumstances,  the  blood  was  not  examined  during  the  month  previous 
to  the  patient's  death,  which  occurred  on  October  20th  from  asthenia. 
Judging  from  the  extreme  pallor  of  the  skin  and  mucous  membranes, 
from  the  increased  dyspnoea,  palpitation,  and  prostration,  the  corpuscular 
poverty  of  the  blood  must  have  still  further  increased. 

Autopsy  Seventeen  Hours  after  Death. — The  surface  of  the 
body  was  intensely  anaemic.  Rigor  mortis  was  present.  There  was  no 
oedema.    The  surface  of  the  penis  showed  no  cicatrices. 

Head.  The  scalp  and  calvaria  were  very  anaemic.  The  brain  through- 
out was  normal  in  consistency,  but  intensely  anaemic.  The  convolutions 
were  pale  and  markedly  atrophic.  There  was  a  great  deal  of  serum  in 
the  meshes  of  the  pia  mater  covering  the  entire  vertex.  The  vessels  at 
the  base  of  the  brain  were  normal. 

There  was  a  very  small  amount  of  fat  of  very  pale  color  beneath  the 
skin,  and  the  muscular  tissue  in  the  abdominal  wall  was  of  a  pale  red 
color.  The  position  of  the  organs  in  the  abdominal  cavity  was  normal. 
The  peritoneum  was  anaemic. 

Pleural  cavities  contained  no  fluid,  and  there  were  no  pleuritic  ad- 
hesions. 

Heart.  The  pericardium  was  anaemic,  and  contained  two  ounces  of 
straw-colored  serum.  The  heart  was  slightly  larger  than  normal :  its 
muscular  tissue  was  pigmented  and  anaemic,  and  contained  a  great  deal 
of  fat.  All  its  cavities  were  dilated,  and  contained  pale  yellowish  clots 
and  watery  blood.  The  valves  were  normal.  There  was  a  very  small 
amount  of  pericardial  fat.  The  coronary  arteries  were  normal.  The 
aorta  was  normal. 

Lungs  were  pale  and  very  ©edematous.  They  were  fairly  well  supplied 
with  air.  The  bronchial  tubes  contained  frothy  mucus  and  pus.  The 
mucous  membrane  of  the  bronchi  was  intensely  anaemic. 

Spleen  was  double  the  normal  size.  It  was  normal  in  consistency,  and 
deeply  pigmented. 

Kidneys.  The  left  was  larger  than  normal.  The  capsule  was  not 
adherent ;  the  surface  was  smooth  and  pale ;  the  cortex  was  swollen ;  and 
the  markings  were  very  indistinct.  The  right  was  normal  in  size ;  the 
capsule  was  not  adherent ;  its  surface  was  a  trifle  granular  and  con- 
gested ;  its  markings  were  indistinct.  There  was  fat  in  the  cortex  and 
pyramids  of  both  kidneys. 

Stomach  contained  a  small  quantity  of  fluid  food.  The  mucous  mem- 
brane in  contact  with  the  food  was  macerated,  and  the  veins  of  the  sub- 
mucosa  in  the  fundus  of  the  stomach  were  prominent.  The  mucous 
membrane  of  the  stomach  not  in  contact  with  its  fluid  contents  was  pale 


KINNICUTT,   ATROPHY  OF   THE   GASTRIC   TUBULES.  429 


and  smooth,  and  to  the  unaided  eye  appeared  normal.  The  stomach  wall, 
especially  that  portion  of  it  in  contact  with  the  fluid,  appeared  thinner 
than  normal.    The  calibre  of  the  pylorus  was  normal. 

The  oesophagus  was  normal. 

The  pancreas  was  normal  in  size,  and  anaemic. 

The  mucous  membrane  of  the  duodenum  was  pale,  and  covered  with 
light  colored  bile.    The  orifice  of  the  common  bile  duct  was  pervious. 

Liver  was  normal  in  size.  The  gall  bladder  was  normal.  There  was  a 
great  deal  of  fat  in  the  liver,  and  its  cut  surface  was  everywhere  stained 
with  bile. 

Intestines.  The  mucous  membrane  of  the  intestines  was  ansemic 
throughout.    The  muscular  wall  was  normal. 

Suprarenal  capsules  w7ere  normal  in  size ;  the  cortex  of  each  contained 
a  very  great  deal  of  fat. 

Bladder,  urethra,  and  thoracic  duct  were  normal. 

Histological  Examination. — Heart.  The  muscular  tissue  in  the 
walls  of  the  auricles  was  granular  and  moderately  fatty. 

The  muscle  of  the  right  ventricular  Avail  contained  a  great  deal  of  fat ; 
hardly  any  of  the  transverse  strise  could  be  seen,  and  many  of  the  cells 
had  undergone  complete  fatty  metamorphosis.  The  fatty  degeneration 
was  still  more  marked  in  the  wall  of  the  left  ventricle,  where  extensive 
areas  of  muscular  tissue  had  undergone  fatty  degeneration,  and  nowhere 
in  them  could  the  transverse  strise  be  seen.  There  was  only  a  trace  of  fat 
in  the  planes  of  fibrous  tissue  in  the  ventricular  walls.  The  bloodvessels 
were  normal. 

Suprarenal  capsules.  There  were  extensive  areas  of  fat  in  the  cortex  of 
each  organ.  In  places  the  parenchyma  of  the  organs  had  so  completely 
degenerated  that  only  the  stroma  could  be  recognized,  infiltrated  with  fat. 
Some  of  these  areas  of  fat  were  very  sharply  defined,  the  cortex  in  their 
immediate  neighborhood  beiug  normal.  The  medulla  of  each  capsule 
was  normal. 

Kidneys.  The  epithelium  lining  the  tubules  everywhere  had  under- 
gone fatty  degeneration.  The  fat  was  more  abundant  in  the  tubes  of  the 
cortex  and  in  the  collecting  tubes.  Many  of  the  tubes  appeared  filled 
with  oil  globules  of  various  sizes.  There  were  granular  casts  in  the 
straight  and  collecting  tubes.  The  fat  was  not  confined  to  the  tubules, 
but  was  seen  in  very  fine  globules  in  the  stroma.  When  hardened  in 
alcohol  and  stained  with  carmine,  the  stroma  wras  seen  to  contain  many 
small  round  cells,  in  places,  in  aggregations  of  considerable  size. 

Spleen.  The  microscopic  examination  of  the  spleen  was  negative. 

Liver.  There  was  a  very  great  deal  of  fat  in  the  liver.  Very  generally 
the  fat  was  evenly  distributed  throughout  the  lobules  ;  some  of  the  lobules, 
however,  were  more  fatty  at  the  periphery  than  in  the  interior.  The 
central  vessels  were  dilated,  and  the  liver  cells  in  their  neighborhood 
were  atrophied. 

Brain.  The  microscopical  examination  of  the  vessels  of  the  brain 
revealed  nothing  unusual. 

Sympathetic  ganglia.  The  ganglia  of  the  sympathetic  nerves  were 
normal. 

Stomach.  The  mucous  membrane  of  the  stomach  consisted  of  a  stroma 
everywhere  infiltrated  with  the  small,  round  cells  so  common  in  inflam- 
matory processes.  Sections  for  microscopic  examination  were  made 
from  the  pylorus  and  at  varying  distances  along  the  greater  and  lesser 


430     KINNICUTT,  ATROPHY   OF   THE   GASTRIC  TUBULES. 


curvatures ;  and  of  the  anterior  and  posterior  walls,  to  the  level  of  the 
fluid  within  the  organ.  Extensive  areas  of  the  mucous  membrane  pre- 
sented no  trace  of  the  gastric  tubules.  In  none  of  the  sections  were  nor- 
mal tubules  found  :  in  several,  the  more  superficial  portions  of  the  tubules 
were  recognizable,  lined  with  cylindrical  epithelium.  The  epithelium  in 
the  recent  state  was  granular  and  fatty  ;  small  granules  of  fat  were  seen 
in  the  stroma  of  the  mucosa.  There  were  numerous  droplets  of  hyaline 
material  which  was  soluble  in  alcohol  when  submitted  to  its  action  for 
weeks.  It  was  not  readily  colored  by  osmic  acid.  It  did  not  dissolve  in 
ether,  and  it  stained  slowly  with  the  aniline  colors.  This  hyaline  material 
in  places  took  the  shape  of  the  tubules.  Near  the  surface  of  the  mucosa 
there  were  seen  irregular  flat  cells  which  might  be  regarded  as  coming 
from  the  deeper  portion  of  the  gastric  tubules.  These  were  granular  and 
distinctly  nucleated.  There  were  numerous  small  bodies,  many  of  them 
triangular,  highly  refractive,  the  size  of  pus  cells,  seen  generally  dis- 
tributed throughout  the  mucous  membrane.  In  places  they  were  aggre- 
gated into  colonies.  They  stained  very  slowly  with  the  aniline  dyes,  not 
at  all  with  osmic  acid  ;  were  dissolved  in  alcohol  after  the  lapse  of  seven 
to  ten  days. 

The  submucosa  wras  normal.    The  muscularis  mucosae  wTas  normal. 
The  muscular  wall  of  the  stomach  was  normal.   The  bloodvessels  were 
normal. 

The  intestines  were  not  examined. 

Marrow.  There  was  no  fat  in  the  marrow  of  the  long  or  short  bones. 
The  marrow  in  both  localities  was  similar  in  appearance  to  the  unaided 
eye,  and  was  the  same  under  the  microscope.  The  absence  of  fat  was  the 
special  feature  noticeable.  There  was  an  absence  of  multinuclear  cells. 
Several  of  the  Charcot-Neumann  crystals  were  seen  in  the  marrow  of  both, 
the  long  and  short  bones.    There  were  no  nucleated  red  cells  seen.1 

Resume.—  Clinical.  A  history  of  periodical  alcoholism  ;  of  excellent 
health  previous  to  eight  months  before  the  patient's  admission  to  the 
hospital ;  of  anorexia  and  inability  to  take  food  for  four  months ;  of  the 
symptoms  of  a  gradually  developing  anaemia  and  of  prostration ;  of  an 
excessive  and  rapid  loss  of  flesh.  The  occurrence  of  retinal  hemorrhages, 
the  presence  of  an  irregular  temperature  curve ;  continuous  emaciation, 
and  rapidly  increasing  asthenia  during  the  period  of  observation. 
Megalocytes  and  poikilocytes  present  in  the  blood  in  large  numbers ; 
microcytes  in  considerable  number.  Red  blood-corpuscles  finally  re- 
duced to  1,020,950 ;  the  relative  percentage  of  haemoglobin  remaining 
normal.  Death  by  asthenia  three  months  after  admission  to  the  hospital. 

Anatomical.  Extreme  anaemia  and  emaciation ;  fatty  changes  in  all 
the  organs  ;  disappearance  of  fatty  tissue  in  the  marrow  of  the  long 
bones ;  almost  complete  destruction  of  the  secretory  tubules  of  the 
stomach. 

1  Dr.  Ferguson,  during  the  past  two  years,  has  made  histological  examinations  of  more  than  one 
hundred  stomachs  of  patients  dying  of  various  diseases,  and  he  informs  me  that  in  this  series  he  has 
never  observed  either  the  presence  in  the  mucosa  of  the  peculiar  hyaline  material  noticed  in  the  above 
cases,  or  a  similar  extensive  destruction  of  the  gastric  tubules.  Pernicious  anaemia  was  not  present  in 
any  of  the  cases  of  the  series. 


KINNICUTT,   ATROPHY  OF   THE   GASTRIC  TUBULES.  431 

Remarks. — The  patients  whose  histories  have  been  related,  presented 
a  clinical  picture,  in  a  very  typical  way,  of  the  group  of  symptoms 
which  are  regarded  as  pathognomonic  of  progressive  pernicious  anaemia. 

Both  patients  gave  a  history  of  a  probably  excessive  use  of  alcohol. 
The  influence  of  this  habit  in  the  production  of  the  pathological  process 
is  difficult  to  determine.  In  none  of  Fenwiek's1  cases  was  there  a  history 
of  alcoholism  ;  and  no  mention  of  it  occurs  in  Nolen's,2  Quincke's,3  and 
Brabazon's4  cases.  On  the  other  hand,  the  alcoholic  habit  extended 
over  a  period  of  many  years  in  Henry's  and  Osier's5  case,  and  was  re- 
garded by  them  as  "  pla}dng  a  part  in  the  causation  of  the  atrophy."  In 
three  out  of  eleven  cases  of  alcoholism,  Hanfield  Jones6  found  extensive 
destruction  of  the  gastric  tubules.  In  Dr.  Ferguson's7  series  of  one 
hundred  cases,  in  which  a  histological  examination  of  the  stomach  was 
made,  the  only  considerable  degeneration  and  destruction  of  the  tubulesr 
exclusive  of  the  author's  cases,  was  observed  in  patients  who  had  suffered 
from  chronic  alcoholism. 

In  both  cases  the  interesting  and  now  well  recognized  fact  in  this  dis- 
ease, of  a  richness  in  haemoglobin  of  the  individual  corpuscles  greatly  in 
excess  of  that  observed  in  all  other  forms  of  ansemia,  indeed,  equalling 
that  present  in  health,  is  clearly  illustrated.  An  increase  in  the  cor- 
puscular richness  of  the  blood  and  a  proportionate  increase  in  the  per- 
centage of  haemoglobin,  corresponding  wTith  temporary  improvements  in 
the  patient's  condition,  is  noticeable  in  Case  I.  It  will  be  seen  that  the 
average  daily  excretion  of  urea  was  normal,  throughout  the  period  of 
observation,  in  both  cases. 

The  history  in  Case  I  of  gastric  symptoms,  anorexia,  and  emaciation, 
distinctly  and  for  a  long  period  preceding  the  appearance  of  anaemia, 
and  in  Case  II.,  the  existence  of  anorexia  and  inability  to  take  food, 
with  rapid  and  excessive  loss  of  flesh,  also  distinctly  antedating  the  de- 
velopment of  anaemic  symptoms,  strongly  favor  the  view,  from  a  clinical 
standpoint,  of  the  secondary  occurrence  of  the  latter.  The  pathological 
considerations  in  support  of  the  primary  nature  of  the  gastric  atrophy, 
will  be  discussed  later.  It  remains  to  consider  the  pathogenesis  of  the 
gastric  lesion. 

That  the  changes  observed  in  the  mucous  membrane  of  the  stomach 
were  not  due  to  post-mortem  solution  or  cadaveric  change,  did  not  admit 
of  question  to  the  observers.  In  both  cases,  all  the  sections  described, 
were  made  above  the  point  of  contact  of  the  fluid  in  the  stomach  with  the 
mucous  membrane;  sections  of  the  lesser  curvature  and  in  the  immedi- 
ate neighborhood  of  the  pylorus,  showed  the  presence  of  changes  similar 
in  kind  and  almost  similar  in  degree  to  those  found  in  other  areas  not 
in  contact  with  the  fluid;  the  mucous  membrane  aboye  the  poinl  of 


1  Loc.  cit.     2  Loc.  cit.     3  Loc.  cit.      4  Loc.  cit.      5  Luc.  cit.     0  Loc.  cit.      •  Not  yet  published. 


432     KINNICUTT,  ATROPHY   OF   THE   GASTRIC  TUBULES. 

contact  with  the  fluid,  presented  no  trace  of  superficial  softening.  The 
more  superficial  portions  of  the  glandular  structure  were  those  least 
involved,  the  greatest  destruction  affecting  the  deeper  portions  of  the 
tubules.1  A  post-mortem  solution  capable  of  causing  such  general  de- 
struction of  the  deeper  portions  of  the  secretory  structures,  would  very 
certainly  involve  the  subjacent  tissues;  and  finally  there  existed  a  very 
general  infiltration  of  the  mucous  membrane  with  new  elements  (small 
cells  of  inflammatory  origin). 

Pathological  as  well  as  clinical  considerations  strongly  support  the 
view  that  the  very  extensive  destruction  of  the  gastric  tubules  cannot 
be  regarded  as  secondary,  and  as  similar  in  its  origin  to  the  fatty  de- 
generation observed  in  the  other  viscera.  Extensive  fatty  changes  of 
the  viscera  are  observed  in  various  chronic  non-infectious  and  acute  in- 
fectious diseases,  with  a  very  moderate  degree  of  fatty  degeneration  and 
with  little,  if  any,  destruction  of  the  glandular  structures  of  the  stomach. 

Fatty  degeneration  of  the  various  tissues  of  the  body  is  justly  regarded 
in  many  instances  as  a  consequence  of  an  impediment  to,  or  an  arrest  of 
nutrition ;  the  dense  and  general  small-celled  infiltration  of  the  gastric 
mucosa  cannot,  however,  be  regarded  as  the  result  of  an  impaired  nutrition, 
and  in  itself  would  account  for  the  degeneration  and  atrophy  of  the  gastric 
tubules. 

Gradual  destruction  of  the  glandular  tissues  of  the  stomach,  conse- 
quent impaired  nutrition  and  fatty  changes  in  the  other  viscera,  would 
seem  to  represent  the  probable  sequence  in  the  author's  cases. 

The  supposition  of  a  creeping  ulceration  in  explanation  of  the  gastric 
lesiou  is  untenable.  That  the  degenerative  changes  were  not  dependent 
upon  an  arterio-sclerosis  or  endarteritis,  is  evident  from  the  absence  of 
appreciable  change  in  the  gastric  vessels. 

Hanfield  Jones,2  as  a  result  of  his  extensive  histological  investigations, 
flrst  expressed  the  opinion  that  in  some  instances  "  the  gastric  tubules 
undergo  spontaneous  degeneration,  or  at  least  not  from  atrophic  pressure 
of  new  formed  fibroid  tissue,"  and  stated  that  "the  mucous  membrane 
then  presented  a  mere  mass  of  granular  and  colloid  debris,  with  inter- 
spersed fat  globules  and  fatty  matter."  Other  observers,  who  believe 
that  a  primary  atrophy  of  the  stomach  occurs,  maintain  that  it  results 
from  interstitial  inflammation  alone. 

In  the  author's  cases  the  general  and  very  dense  small-celled  infiltra- 
tion of  the  mucous  membrane  points  strongly  to  the  probable  dependence 
of  the  atrophy  upon  an  inflammatory  process.  Other  elements  observed 
in  the  gastric  mucosa  may  be  regarded  as  the  probable  products  of  de- 
generating tissues, 

A  study  of  the  cases  related  would  seem  to  justify  the  opinion  pre- 


1  A  similar  condition  was  observed  by  Fenwick,  Osier,  and  others. 


2  Loc.  cit. 


MIDDLETON,  SUBCUTANEOUS   NODULES  I N   HANDS.  433 


viously  expressed  that  "  a  primary  atrophy  of  the  gastric  mucous  mem- 
brane occurs,  and  that  in  this  lesion  is  to  be  found  an  explanation  of 
certain  cases  of  pernicious  ansemia." 


A  CASE  OF  SUBCUTANEOUS  NODULES  IN  THE  HANDS  OF 
A  EHEUMATIC  PATIENT. 

By  George  S.  Middleton,  M.A.,  M.D., 

ASSISTANT  PHYSICIAN  TO  THE  ROYAL  INFIRMARY,  GLASGOW  ;  ASSISTANT  TO  THE  PROFESSOR  OF 
PRACTICE  OF  PHYSIC,  UNIVERSITY  OF  GLASGOW. 

Mrs'.  L.,  aged  thirty-nine,  presented  herself  at  the  outdoor  depart- 
ment of  the  Glasgow  Royal  Infirmary  in  November,  1886,  complaining 
of  rheumatism,  and  of  painful  subcutaneous  growths  on  the  fingers  of 
both  hands. 

She  had  an  attack  of  acute  rheumatism  when  thirteen  years  of  age, 
and  a  second  in  September,  1883.  Between  these  two  attacks,  and  since 
the  last  one,  she  has  frequently  suffered  from  rheumatic  pains  in  various 
joints,  such  as  the  knees,  ankles,  wrists,  and  finger-joints,  accompanied 
by  some  swelling  of  the  parts,  but  not  with  distinct  fever,  and  not  con- 
fining her  to  bed,  unless  occasionally  for  a  day.  There  is  no  cardiac 
murmur.  There  is  nothing  in  the  history  to  suggest  the  existence  of  a 
syphilitic  taint. 

The  swellings  on  the  fingers  began  during  convalescence  from  the 
second  attack  of  acute  rheumatism,  in  September,  1883.  According  to 
the  patient's  statement,  they  were  not  at  first  permanent,  coming  and 
going ;  but  they  have  been  present  more  or  less,  as  they  are  now,  since 
early  in  1884,  though  they  are  said  to  vary  in  size  and  in  hardness. 

They  began  as  flattened  elevations  of  the  skin,  and  the  most  recent 
ones  present  something  of  that  appearance  now.  But  the  majority  are 
distinctly  circumscribed  tumors,  some  the  size  of  a  pea,  others  the  size 
of  a  small  hazelnut.  The  larger  ones  are  lobulated,  being  apparently 
composed  of  two  or  more  that  have  coalesced.  A  few  of  them  feel  soft 
and  elastic,  but  in  none  is  there  any  indication  of  fluctuation  ;  the  rest 
are  hard,  like  cartilage,  but  none  have  either  a  chalky  or  a  bony 
hardness.  During  the  eight  months  she  has  been  under  observation,  it 
cannot  be  said  that  they  have  distinctly  varied  either  in  size  or  hardness, 
although  she  herself  is  of  opinion  that  they  have. 

The  most  striking  swellings  are  on  the  flexor  aspects  of  the  fingers, 
which,  as  will  be  seen  in  the  woodcut  (from  a  photograph  by  Dr.  Mac- 
ewen),  present  something  of  the  appearance  of  a  knotted  blackthorn 
stick.    There  are  between  twenty  and  thirty  growths  on  the  fingers  of 

NO.  CLXXXVIII. — OCTOBER,  1887.  28 


434     MIDDLETON,  SUBCUTANEOUS  NODULES   IN  HANDS. 

the  right  hand,  and  between  ten  and  twenty  on  the  left ;  it  is  difficult  to 
state  the  exact  number,  owing  to  the  fact  that  so  many  have  coalesced. 
They  are  freely  movable  on  the  subjacent  structures,  but  the  skin  is 
adherent  to  all  but  two  of  these  tumors  on  the  fingers.    Over  many  of 


them  the  skin  is  thickened,  and  the  superficial  layers  are  rubbed  off. 
Many  of  them  present  a  dull,  whitish  appearance,  intensified  by  drawing 
the  skin  tightly  over  them.  They  are  itchy,  and  sore  when  rubbed.  At 
times  they  are  quite  free  from  pain,  but  they  are  very  liable  to  become 
painful ;  and  the  pain  in  them  is  most  acute  when  they  are  growing, 
during  the  prevalence  of  east  wind,  and  just  prior  to  rainy  weather. 
Putting  the  hands  in  cold  water  always  causes  pain.  They  have  occa- 
sionally bled,  as  after  rubbing  them,  or  after  a  heavy  washing  of  clothes. 
They  have  never  suppurated. 

A  few  similar  swellings  are  said  to  have  been  seen  on  the  toes,  but 
have  disappeared.  There  are  none  on  the  scalp,  and  none  on  the  ears. 
The  only  other  situation  where  a  swelling  of  apparently  the  same  char- 
acters is  met  with  is  at  the  right  elbow.  On  the  right  olecranon  there  is 
a  prominent  swelling,  which  appears  to  consist  of  a  deep,  hard,  bony 
growth,  immovable,  and  quite  different  from  the  above,  with  a  mass  of 
softer  material  like  a  bursa  over  it.    Distal  to  this,  there  is  a  small, 


MIDDLETON,  SUBCUTANEOUS   NODULES  IN  HANDS.  435 

movable  tumor  felt  under  the  skin,  to  which,  however,  it  is  not  adherent, 
and  probably  of  the  same  nature  as  the  growths  above  described. 

At  the  knuckles  there  are  smaller  swellings,  which,  however,  do  not 
seem  to  have  attracted  her  attention.  They  are  not  like  the  above,  but 
resemble  fusiform  enlargements  of  the  sheaths  of  the  tendons,  with  which 
alone  they  move.  They  are  not  so  circumscribed  as  those  already 
described,  and  they  have  no  connection  with  the  skin.  They  are  present 
on  all  the  knuckles,  except  those  of  the  little  finger  and  thumb  on  the 
right,  and  of  the  thumb  on  the  left  hand. 

There  is  distinct  crepitation  felt  at  the  knuckles  of  the  left  hand, 
especially  on  the  flexor  aspect,  and  on  the  ring  finger  more  than  else- 
where. In  the  sheaths  of  the  flexor  tendons,  both  above  and  below  the 
annular  ligament  at  both  wrists,  there  is  crepitation  on  movement,  and 
several  bodies  are  felt  moving  along  with  the  movement  of  the  tendons, 
but  not  capable  of  being  pressed  from  the  distal  to  the  peripheral  side  of 
the  ligament.  They  resemble  the  loose  bodies  sometimes  found  in  this 
situation,  but  are  less  movable  and  fewer  in  number. 

Various  remedies  were  tried  to  relieve  the  pain,  the  one  that  seemed 
of  most  use  being  a  combination  of  bromide  of  potassium  and  liquor 
arsenicalis. 

The  case  was  shown  at  the  Pathological  and  Clinical  Society  of  Glas- 
gow in  December,  1886,  wThen  Drs.  Macewen  and  Newman  were  appointed, 
along  with  myself,  a  committee  for  its  further  investigation.  Recently, 
having  obtained  the  patient's  consent,  Dr.  Macewen  removed  a  mass 
from  the  front  of  the  left  thumb,  and  found  it  to  consist  of  two  separate 
tumors,  the  one  single,  the  other  composed  of  three  that  had  coalesced. 
The  tumors  were  adherent  to  the  skin,  hard,  and  distinctly  circumscribed, 
but  without  any  capsule ;  and  in  their  removal  the  sheath  of  the  tendon 
was  exposed,  but  there  was  no  adhesion  to  it.  On  section,  the  tumor 
was  white  and  glistening,  like  fibrous  tissue. 

On  microscopic  examination  we  found  "that  where  the  tumor  has 
approached  most  closely  to  the  surface,  and  is  most  dense,  the  papillae  of 
the  skin  have  become  obliterated,  and  the  layer  of  epithelium  attenuated, 
the  stratum  corneum  being  reduced  to  about  one-third  of  its  normal 
size.  In  passing  from  that  area,  papillae  again  present  themselves,  small 
in  size,  and  gradually  increasing  on  receding  from  this  centre.  Where 
the  papillae  are  lost,  the  bloodvessels  have  also  in  the  main  disappeared. 
The  growth  as  a  whole  is  made  up  of  connective  tissue  in  various  stages 
of  development.  In  its  substance  there  are  scarcely  any  bloodvessels, 
but  at  its  periphery  the  arteries  seem  to  be  abnormally  numerous,  and 
in  many  instances  their  coats  are  greatly  thickened  by  infiltration  with 
cells,  the  tunica  intima  being  frequently  particularly  affected.  In  one 
instance,  besides  accumulation  of  cells  in  the  intima  ami  in  the  adven- 
titia,  there  is  a  collection  of  cells  dissecting  the  middle  coat,  which  is 


436      HALSTED,  CIRCULAR   SUTURE   OF  INTESTINE. 


also  greatly  thickened.  Collections  of  these  cells  frequently  extend  to  a 
considerable  distance  from  the  vessels,  and  in  many  sections  they  map 
out  the  course  of  the  minute  vessels  in  the  papilla?  of  the  skin.  Glandular 
tissue  and  fat  are  almost  entirely  absent." 

As  regards  its  structure,  the  most  striking  feature  is  the  condition  of 
the  vessels,  from  which  it  might  be  inferred  that  the  lesion  has  its  origin 
in  them,  as  if  from  some  irritant  carried  by  the  blood. 

The  close  relationship  between  the  origin  of  these  tumors  and  an 
attack  of  rheumatic  fever,  and  the  fact  that  they  are  now  also  most 
painful  when  she  suffers  from  rheumatic  pains  in  the  joints,  lead  me  to 
believe  that  they  are  of  rheumatic  origin,  a  belief  strengthened  by  the 
absence  of  anything  in  her  past  history  to  suggest  a  syphilitic  taint. 

In  connection  with  this  case,  my  attention  has  been  directed  to  a  paper 
on  "  Subcutaneous  Nodules  connected  with  Fibrous  Structures  Occurring 
in  Children  the  subjects  of  Eheumatism  and  Chorea,"  by  Drs.  Barlow 
and  Warner,1  and  to  cases  shown  at  the  Clinical  Society,  London,  by 
Drs.  Dyce  Duckworth,2  Stephen  Mackenzie,3  and  Kingston  Fowler/  The 
case  above  recorded  differs  in  many  respects  in  its  clinical  features  from 
those  recorded  by  them,  while  in  its  microscopic  characters  it  closely 
resembles  the  tumors  they  examined,  with,  however,  some  points  of 
difference.  I  am  inclined,  therefore,  to  agree  with  Dr.  Duckworth  when 
he  says  that  "  a  more  extended  study  of  these  cases  will  show  that  there 
are  several  types  or  varieties  of  them."  Indeed,  since  my  attention  has 
been  directed  to  the  subject,  I  have  been  led  to  believe  that  subcutaneous 
nodules  on  rheumatic  hands  are  more  common  than  one  would  suppose, 
from  the  references  made  to  them  in  literature,  by  the  fact  that  I  have 
seen  at  the  Royal  Infirmary  Dispensary  several  cases  presenting  such 
nodules. 

Glasgow,  July,  1887. 


CIECULAR  SUTUEE  OF  THE  INTESTINE— AN  EXPERIMENTAL 

STUDY.5 

By  William  S.  Halsted,  M.D., 

OF  XIW  TOEK. 

Among  the  most  brilliant  triumphs  of  modern  surgery  are  those 
which  have  attended  operations  involving  laparotomy.  We  can  offer  a 
scientific  explanation  why  many  abdominal  operations — above  all,  ovari- 
otomy— should  succeed  so  well  even  without  the  use  of  antiseptics.  The 

1  Trans  Internat.  Mod.  Congress,  London,  1881,  vol.  iv.  p.  116. 

2  Clin.  Soc  Trans  ,  vol.  xvi.  pp.  52,  190  3  Ibid  ,  p.  1S8.  *  Ibid  ,  vol.  xvii.  p.  65. 

5  My  experiments  were  completed  April  1,  188Y,  and  in  a  lecture  which  I  delivered  at  the  Harvard 
Medical  School,  April  5,  1887,  I  gave  in  substance  what  I  have  written  for  this  article. 


HALSTED,  CIRCULAR   SUTURE   OF   INTESTINE.  437 


chief  danger  of  these  operations  is  the  development  of  peritonitis  of  a 
septic  or  purulent  nature.  Contrary  to  former  beliefs  Wegner1  demon- 
strated experimentally  that  the  mere  exposure  of  the  peritoneum  to  the 
air  does  not  cause  peritonitis.  The  recent  experiments  of  Grawitz2  have 
shown  that  the  access  of  the  microorganisms  of  suppuration  to  the  peri- 
toneal cavity  does  not  alone  suffice  to  induce  peritonitis.  The  absorbing 
power  of  the  peritoneal  surfaces  is  very  great  and,  under  favorable  cir- 
cumstances, pyogenic  substances  are  quickly  absorbed  from  the  peritoneal 
cavity  without  causing  suppurative  inflammation.  In  confirmation  of 
the  experiments  of  Grawitz  I  have  inserted  pure  cultures  of  the  pus 
organisms,  as  well  as  small  pieces  of  suppurating  tissue  and  particles  of 
feces,  into  the  peritoneal  cavities  of  dogs  without  producing  peritonitis. 

Accessory  causes  must  be  present  in  order  that  pyogenic  substances 
may  induce  purulent  peritonitis.  These  accessory  conditions,  various  as 
they  may  be,  have  in  common  the  attribute  that  they  prevent  absorption 
or  removal  from  the  peritoneal  cavity  of  pyogenic  substances,  more  par- 
ticularly of  the  bacteria  of  suppuration. 

Without  entering  into  a  detailed  consideration  of  these  conditions,  the 
following  may  be  mentioned  as  of  especial  importance  in  surgical  opera- 
tions involving  the  peritoneum :  the  presence  in  the  peritoneal  cavity  of 
blood  or  other  stagnating  fluids,  the  existence  of  necrotic,  wounded,  or 
diseased  tissue  in  connection  with  the  peritoneal  cavity,  and  the  presence 
of  some  focus  from  which  pyogenic  bacteria  may  enter  the  peritoneal 
cavity  in  larger  number  or  more  rapidly  than  they  can  be  absorbed. 
It  is  evident  that  bacteria,  which  otherwise  would  be  readily  absorbed, 
may  take  lodgement  and  grow,  if  they  find  in  the  peritoneum  stagnating 
nutritive  fluids  or  ulcerated  and  necrotic  tissue.  For  manifest  reasons 
dead  spaces,  which  play  such  an  important  role  in  suppurative  inflam- 
mations elsewhere,  are  less  likely  to  be  formed  in  the  peritoneal  cavity 
than  in  most  other  situations. 

The  experimental  results  which  have  been  mentioned  and  the  deduc- 
tions from  them  enable  us  to  explain  the  brilliant  success  of  skilful 
ovariotomists,  even  when,  like  Lawson  Tait,  they  ostentatiously  discard 
the  use  of  antiseptics. 

In  striking  contrast  to  the  results  of  ovariotomy  are  those  of  intes- 
tinal suture.  Not  but  that  here,  too,  brilliant  successes  have  been  re- 
corded, but  the  death-rate  attending  enterorrhaphy  has  been  large,  and,  in 
general,  the  operation,  even  in  the  hands  of  the  most  skilful  surgeons 
has  been  capricious  in  its  results.  While  admitting  that  an  operation  so 
delicate  and  so  difficult  in  its  technique  as  enterorrhaphy  should  be  judged 
not  by  statistics  collected  at  random  from  all  possible  sources,  but  by 
the  results  of  individual  operators  of  approved  knowledge  and  skill,  it 


1  Wegner  .  Arch.  f.  klin.  Chirurgie,  Bil.  xx. 


2  Grawitz:  Charite-Annalon,  Jahrg.  xi. 


488      HALSTED,  CIRCULAR   SUTURE   OF  INTESTINE. 


yet  remains  true  that  even  from  this  point  of  view  the  results  are  not 
satisfactory,  although  they  are  such  as  to  encourage  further  efforts  in 
perfecting  the  operation. 

In  the  hope  that  an  experimental  investigation  of  the  subject  of  intes- 
tinal suture  might  contribute  somewhat  to  our  knowledge  of  the  causes 
of  failure  as  well  . as  of  the  conditions  of  success  of  enterorrhaphy,  I  have 
undertaken  during  the  past  winter  a  series  of  experiments  in  the  Patho- 
logical Laboratory  of  the  Johns  Hopkins  University,  in  Baltimore.  I 
wish  on  this  occasion  to  express  my  thanks  to  Prof.  Wm.  H.  Welch,  the 
Director  of  the  Laboratory,  for  his  kindness  and  advice,  and  also  to 
acknowledge  my  indebtedness  to  Dr.  F.  P.  Mall,  Fellow  in  Pathology  of 
Johns  Hopkins  University,  for  his  kind  assistance  in  the  operations,  and 
especially  for  calling  my  attention  to  many  points  concerning  the  minute 
anatomy  of  the  intestine.  Dr.  Mall's  suggestions  were  of  great  value  to 
me. 

The  experiments  were  performed  upon  dogs,  anaesthetized  usually  with 
morphine  and  ether  ;  they  include  sixty-nine  circular  resections  and 
circular  sutures  of  the  small  intestine. 

The  history  of  the  operation  of  intestinal  suture  has  been  described 
so  often  and  so  well  that  it  is  not  necessary  in  an  experimental  study  of 
the  subject  to  go  over  this  historical  ground  again. 

Before  describing  my  experiments,  I  wish  to  call  attention  to  certain 
points  relating  to  the  anatomy  of  the  intestinal  wall,  a  knowledge  of 
which  is  of  the  utmost  importance  to  the  surgeon  who  performs  intes- 
tinal suture.  In  looking  through  the  literature  of  intestinal  suture  I 
cannot  find  that  any  one  has  called  sufficient  attention,  from  a  surgical 
point  of  view,  to  the  structure  of  the  different  coats  of  the  intestine, 
particularly  to  their  physical  properties.  Indeed,  the  descriptions  in 
surgical  text-books,  as  well  as  in  monographs  and  articles  treating  espe- 
cially of  intestinal  suture,  and  the  drawings  which  are  frequently  inserted 
to  elucidate  the  subject,  lead  me  to  believe  that  the  current  ideas  among 
surgeons  are  not  only  incomplete,  but  absolutely  incorrect  as  regards 
some  important  details  in  the  structure  of  the  intestinal  coats.  If  these 
errors  related  to  matters  of  only  histological  interest  their  practical 
bearing  would  be  very  slight,  but  my  experiments  have  led  me  to  attach 
great  weight,  in  the  successful  performance  of  enterorrhaphy,  to  an 
accurate  knowledge  of  the  thickness  and  physical  characters  of  the  sub- 
mucous coat  of  the  intestine,  and  I  am  not  aware  that  the  importance 
of  this  coat  in  connection  with  this  operation  has  hitherto  been  empha- 
sized. 

The  old  views  of  Jobert  and  Lembert  as  to  the  structure  of  the  intes- 
tinal wall  seem  to  have  been  adopted  by  modern  surgeons  with  little  or 
no  modification.  The  peritoneal  coat,  for  instance,  is  believed  to  be 
thick  enough  and  sufficiently  strong  to  hold  a  stitch,  and  the  existence 


HALSTED,   CIRCULAR   SUTURE   OF   INTESTINE.  439 


of  the  submucosa,  for  us  the  most  important  coat,  has  been  generally- 
ignored. 

A  few  quotations  from  recent  writers  will  substantiate  these  statements. 
Thus  Madelung,1  in  his  admirable  contribution  to  intestinal  suture, 
writes,  "  The  needle  now  penetrates  in  the  usual  manner  the  two  ends  of 
the  intestine,  passing  between  serosa  and  muscularis."  Reichel2  insists 
upon  the  accurate  "  adaptation  of  the  two  edges  of  the  wound,  particu- 
larly of  the  serous  coats,"  and,  having  described  the  manner  of  taking 
the  first  row  of  stitches,  continues,  "  over  this  comes  then  the  external 
suture  which  includes  only  the  serosa."  Maydl,3  Kocher,4  and  many 
others  could  be  quoted  in  the  same  sense  to  show  the  prevalence  of  the 
idea  that  intestinal  surfaces  may  be  sutured  by  stitches  including  only 
the  serous  membrane. 

I  fail,  moreover,  to  find  in  the  writings  of  Gussenbauer,  von  Wini- 
warter, Kocher,  Czerny,  Rydygier,  Madelung,  Reichel,  Maydl,  and 
others  the  proper  importance  attached  to  the  inclusion  of  a  portion  of 
the  submucosa  in  suturing  the  intestine.  The  following  quotations  will 
suffice  to  show  how  little  importance,  from  a  surgical  point  of  view,  has 
been  attached  to  the  submucosa. 

Reichel5  completely  ignores  the  existence  of  the  submucosa  when  he 
says,  "  It  is  to  be  recommended  in  making  the  internal  row  of  sutures, 
after  carefully  turning  in  the  mucous  membrane,  to  stick  the  needle 
close  in  front  of  the  edge  of  the  wound  through  the  serosa  and  muscu- 
laris, and  to  draw  it  out  at  the  edge  of  the  wound  between  the  muscularis 
and  mucosa,  and  on  the  other  border  to  proceed  in  reverse  order." 

Maydl,6  too,  recognizes  but  three  coats,  for  he  writes,  "  Then  the  two 
external,  possibly  retracted,  intestinal  coats  are  to  be  drawn  together  by 
means  of  several  stitches  which  grasp  the  entire  thickness  of  the  intes- 
tinal wall  with  the  exception  of  the  already  coaptated  mucous  coats, 
whereby  serous  surfaces  when  present  are  brought  into  broad  apposition." 
Had  Kocher  appreciated  the  resistance  furnished  to  the  needle  on  enter- 
ing the  submucosa,  he  might  have  explained  how  perforation  into  the 
lumen  of  the  gut  is  to  be  avoided,  and  not  merely  have  said,  "  The  wall 
of  the  intestine  is  not  to  be  punctured  in  its  entire  thickness,"7  and  "  we 
passed  the  stitches  according  to  Lembert  through  the  thickness  of  the 
intestinal  wall,  avoiding,  if  possible,  penetrating  the  lumen."8  Czerny, 
who  has  for  a  long  time  devoted  himself  earnestly  and  most  usefully  to 

1  Madelung:  Arch.  f.  klin.  Chirurgie,  Bd.  xxvii.  p  321. 

2  Reichel :  Deutsche  Zeitschrift  f.  Chirurgie,  Bd.  xix.  pp.  26S  and  270. 

3  Maydl :  Allg.  Wien.  med.  Zeitung,  October,  1885,  p.  475. 

4  Kocher:  Centralhlatt  f.  Chirurgie,  1SS0,  No.  29,  p.  406. 

5  Reichel :  Loc.  cit.,  pp.  269  and  270. 
e  Maydl :  Loc.  cit.,  p.  489. 

7  Kocher;  Correspondenzblatt  f.  Schweizer  Aertze,  1S78,  p  155. 

8  Kocher :  Centralblatt  f.  Chirurgie,  July,  1880,  p.  468. 


440      II ALSTE  D,  CIRCULAR  SUTURE   OF  INTESTINE. 

the  subject  of  intestinal  suture,  does  not  refer  to  the  submucosa  in  de- 
scribing the  technique  of  the  operation.1 


Fig.  1. 


mm  \ — fEuymr? 


p.  Peritoneum.    I.  Longitudinal  muscular  coat.    c.  Circular  muscular  coat.    s.  Snbmuc 
mm.  Muscularis  mucosae.    L.  Glands  of  Lieberkiilin. 


Fig.  1,  kindly  drawn  for  me  by  Dr.  Mall,  is  a  diagram  of  the  wall  of 
the  dog's  intestine,  and  is  intended  to  represent  accurately  the  relative 
thickness  of  the  several  coats.  The  serosa  is  prolonged  beyond  the  outer 
muscular  coat  to  emphasize  its  thinness.  Between  the  submucosa  and 
glands  of  Lieberkuhn — in  other  words,  between  it  and  the  lumen  of  the 
intestine — practically  nothing  intervenes ;  and,  literally,  nothing  but  the 
two  layers  of  muscularis  mucosae  and  fibrosa  mucosae  respectively.  Fully 
two-thirds  of  the  thickness  of  the  wall  of  the  intestine  is  mucous  mem- 
brane. When  the  needle,  therefore,  has  been  passed  through  its  outer 
third  it  must  have  entered  the  glands  of  Lieberkuhn  and,  hence,  the 
lumen  of  the  gut.  It  is  an  easy  matter  to  isolate  the  submucosa.  The 
outer  muscular  coats  strip  from  it  readily,  and  the  mucous  membrane 
can  be  rapidly  scraped  off  with  a  knife.  Thus  obtained,  the  submucosa  is 
found  to  be  an  exceedingly  tough,  fibrous  membrane.  It  is  air-tight  and 
watertight,  and  is  the  "  skin  "  in  which  sausage  meat  is  stuffed.  It  is, 
moreover,  the  coat  of  the  intestine  from  which  "  catgut "  is  made. 

A  needle,  on  being  pushed  vertically  through  the  wall  of  the  intes- 
tine, meets  with  considerable  resistance  when  it  reaches  the'  submucosa ; 
and  still  greater  resistance  is  encountered  if  it  be  attempted  to  pass 
the  needle  horizontally  through  its  meshes.  A  delicate  thread  of  this 
tissue  is  very  much  stronger  and  better  able  to  hold  a  stitch  than  is  a 
coarse  shred  of  the  entire  thickness  of  the  muscular  and  serous  coats. 
Upon  the  discovery  of  the  latter  fact,  at  which  I  was,  perhaps,  as  much 
surprised  as  most  surgeons  will  be  at  the  statement  of  it,  it  naturally 


i  Czerny:  Berlin,  klin.  Wochenschrift,  November,  1880,  p.  G41,  et.  seq. 


.HALSTED,  CIKCULAR   SUTURE   OF   INTESTINE.  441 

occurred  to  me  that  it  would,  if  feasible,  be  well  to  include  a  portion  of 
the' submucosa  in  the  suture.  Before  attempting  this,  however,  I  wished 
to  test  the  merits  of  a  suture  which  included  nothing  but  the  serosa  and 
muscularis,  and  I,  therefore,  performed  the  following  experiment : 

Experiment  A.— Small  young  dog.  Operated  on  January  18,  1887. 
Irrigation  with  solution  of  corrosive  sublimate,  1 : 1000.  Needles  with  dulled 
ends  employed  for  sewing.  Circular  resection  of  intestine.  Two  rows  of  in- 
terrupted stitches  passed  as  deep  as,  but  not  including  any  portion  of  sub- 
mucosa — suture  of  muscular  coat.  The  stitches  tore  out  badly  (particularly 
those  of  the  first  row)  and  had  to  be  frequently  retaken. 

January  23.  Dog  found  dead.  Autopsy:  Suppurative  peritonitis;  sutures 
had  given  way  completely. 

Blunt  needles  were  used  in  the  foregoing  experiment  to  enable  me  to 
penetrate  down  to,  and  no  deeper  than  the  submucous  coat.  Dr.  Mall 
had  previously  called  my  attention  to  the  fact  that,  with  the  eye-end  of 
a  needle,  one  could  not  unwittingly  puncture  the  submucosa ;  for  the 
force  required  to  enter  it  at  all  with  the  rounded  end  of  a  needle  is  suf- 
ficient to  perforate  it,  and,  that  too,  not  without  a  positively  unmistak- 
able and  characteristic  jerk.  I  soon  discovered  that,  even  to  the 
sharpened  end  of  a  needle,  sufficient  resistance  is  offered  by  the  sub- 
mucosa to  be  easily  appreciable,  and  that  it  is  possible  and,  with  very 
little  practice,  not  difficult,  to  pick  up  at  each  stitch  a  thread-like  piece 
of  submucosa  without  incurring  the  danger  of  passing  into  the  lumen 
of  the  gut. 

Persuaded  by  Experiment  A,  and  others  of  a  similar  nature,  that  the 
musculo-peritoneai  suture  is  not  to  be  trusted,  I  performed  Experiments 
B  and  C  in  order  to  test  the  advisability  of  taking  up,  with  each  stitch, 
a  thread  of  the  submucosa. 

Experiment  B. — Medium-sized  dog.  Operation  January  18,  1887.  To 
include  in  each  stitch  a  thread  of  submucosa.  Irrigation  with  solution  of 
corrosive  sublimate,  1 : 10,000.  Glass  clamps ;  suture,  catgut.  Two  rows  of 
interrupted  stitches. 

January  25.  Dog  has  been  doing  very  well  ever  since  the- operation. 

February  19.  Apparently  perfectly  well.  Killed.  Autopsy:  Circular  intes- 
tinal wound  perfectly  healed;  no  adhesions,  except  slight  ones  over  the  line 
of  suture  anteriorly. 

I  wish  to  call  attention  here  to  a  point  to  be  emphasized  more  promi- 
nently later,  viz.,  that  whereas  in  Experiments  1  and  2  of  Group  I.,  the 
adhesions  were,  as  we  shall  see,  extensive  enough  to  have  eventually 
caused  death  in  one  case,  and  to  have  threatened  it  in  the  other,  in 
Experiment  B  they  were  strikingly  trivial. 

Experiment  C— Operation  January  20,  1887.  To  reverse  about  one  loot 
of  intestine.  (This  operation  was  done  for  a  purpose  not  belonging  to  the 
subject  of  this  article.)  Steps  of  operation:  1.  Complete  section  of  intestine 
in  two  places,  about  one  foot  apart.  2.  Afferent  (proximal)  ends  stitched 
together.  3.  Efferent  (distal)  ends  brought  together  over  the  line  of  suture 
of  afferent  ends,  and  sutured.    Straight  needles.    Two  rows  of  interrupted 


442      HALSTED,  CIRCULAR   SUTURE   OF  INTESTINE. 


silk  stitches.  With  each  stitch  a  thread  of  submucosa  was  taken  up.  Irri- 
gation with  solution  of  corrosive  sublimate,  1 : 10,000. 

Dog  died  of  shock  a  few  hours  after  operation.  Autopsy,  by  Dr.  Mall: 
Careful  examination  of  suture  made,  to  ascertain  if  any  of  the  stitches  had 
penetrated  into  the  lumen  of  the  gut.;  not  one  was  found  to  have  done  so. 
No  peritonitis. 

This  experiment,  was  a  satisfactory  one  to  me,  in  that  it  demonstrated 
the  feasibility  of  carrying  the  stitches  into  the  submucosa. 
To  satisfy  my  curiosity,  I  made  experiments  D,  E,  and  F. 

Experiment  D. — Small,  brindled  and  white  bulldog  (pup).  Operation 
January  29,  1887.  To  suture  the  submucosa  alone.  1.  Split  muscularis  for 
about  two  centimetres  from  cut  edges  along  mesenteric  and  free  borders  of 
intestine.  2.  Stripped  back  the  muscular  flaps  thus  marked  out  and  exposed 
two  centimetres  of  submucosa.  3.  Applied  two  rows  of  interrupted  stitches 
to  the  exposed  submucosa,  appropriating  but  a  thread  of  it  to  each  stitch.  4. 
Sewed  the  musculo-peritoneal  flaps  together  over  the  line  of  the  circular  suture. 

January  31.  Dog  found  dead.  Autopsy:  Complete  slough  of  flaps,  and 
gaping  of  circular  wound. 

Experiment  E. — Large,  long-haired,  white  dog.  Operation  January  21st. 
Circular  suture  of  submucosa  alone.  I.  Circular  division  of  musculo-peri- 
toneal coat,  and  stripping  off  of  cuffs  to  expose  about  one  centimetre  of  sub- 
mucosa. 2.  Buried-knot  quilt  (vide  Fig.  2  )  stitches  applied  before  completing 
the  section  of  the  gut.  3.  Section  of  gut  completed,  and  buried-knot  quilt 
stitches  tied.  4.  Two  rows  of  continuous  submucosa  suture.  5.  Cut  edges  of 
musculo-peritoneal  cuffs  turned  out,  and  the  under  surface  of  the  cuffs  coap- 
tated,  and  held  by  a  few  stitches. 

February  1 .  Dog  is  dead.  Autopsy :  Submucous  stitches  still  hold ;  but 
gangrene,  starting  from  the  musculo-peritoneal  cuffs,  extends  for  about  one 
foot  above  the  circular  suture. 

Experiment  F. — Operation  same  as  in  Experiment  E.   Dog  died  of  ether. 

We  are  now  prepared  to  consider  my  first  series  of  operations.  In 
order  to  classify  conveniently  the  modes  of  suture,  the  experiments  will 
not  be  numbered  precisely  in  the  order  in  which  they  were  performed. 

Group  I. — Lembert's  Stitches. 

Experiment  1. — Small,  young,  black  bitch.  Operation  January  6,  1887. 
Resection  of  about  two  and  a  half  inches  of  small  intestine.  Glass-slide 
clamps.  Irrigation  with  solution  of  corrosive  sublimate,  1 : 40,000.  Suture, 
fine  sublimate  silk.    Two  rows  of  interrupted  stitches. 

January  7.  Dog  walks  about.  Is  not  much  depressed.  Vomits  occasion- 
ally.   Has  been  seen  to  pass,  per  rectum,  a  few  drops  of  blood-stained  mucus. 

8th.  Dog  is  playful.    No  evidence  of  peritonitis.    Takes  milk. 

11th.  Apparently  perfectly  well. 

February  7.  Dog  emaciated  almost  to  a  skeleton.  Has  refused  food  for 
about  one  week.  Is  evidently  dying  of  starvation.  Killed.  Autopsy:  Line 
of  suture  adherent  to  adjacent  intestines.  Several  acute  bends  in  intestine, 
two  or  three  inches  apart,  caused  by  adhesions.  Intestine  nowhere  dilated. 
Mucous  membrane  at  the  line  of  suture  quite  flat. 

Riedei1  relates  a  similar  case,  the  death  of  a  dog  from  inanition,  due 
to  finger-like  bending  of  the  intestine,  without  dilatation  or  other  evi- 
dences of  obstruction. 

1  Riedel :  Deutsche  Gesellschal't  fur  Chirurgie,  18S3,  p.  25. 


HALSTED,  CIRCULAR   SUTURE  OF  INTESTINE. 


443 


Experiment  2. — Medium-sized,  gray  dog.  Operation  January  19th.  No 
antiseptics.  Irrigation  with  warm  physiological  salt  solution.  No  clamps. 
Suture,  two  rows  of  Lembert's  stitches.  Fear  that  too  much  tissue  has  been 
turned  in. 

January  25.  Dog  has  not  been  very  lively  since  the  operation,  but  takes 
milk  naturally. 

21th.  Dog  appears  better. 
February  1.  Seems  perfectly  well. 

Id.  Killed.  Autopsy:  Omentum  adherent  over  line  of  suture;  numerous 
other  adhesions.  Intestine,  above  suture,  dilated  to  about  four  times  its  natural 
size.    Suture  perfectly  firm. 

Experiments  3,  4,  5. — Operations  December  12,  13,  and  14,  1886.  To 
isolate  loops  of  intestine.  Double  circular  resection,  and  double  suture. 
Suture,  horse -hair. 

All  three  cases  died  within  two  or  three  days  of  the  operation,  from  puru- 
lent peritonitis. 

Experiment  6.  —  Young,  small,  brindled  dog.  Operation  January  9, 
1887.  To  isolate  loop  of  intestine.  1.  Intestine  divided  in  two  places,  about 
one  foot  apart.  2.  Ends  of  gut  thus  isolated,  sewed  together.  3.  The  remain- 
ing ends  stitched  together  to  establish  the  intestinal  continuity.  Irrigation 
with  solution  of  corrosive  sublimate,  1  : 4000.  Glass  clamps.  Suture,  fine 
sublimate  silk.  Czerny's  "Etagennaht."  Operation  lasted  two  hours.  As 
the  abdominal  wall  was  being  sewed,  fresh  ether  was  administered,  and  the 
dog  died  of  respiratory  paralysis.  The  heart  continued  to  beat  for  more  than 
fifteen  minutes  after  the  respiration  had  ceased.  No  attempt  was  made  to 
revive  the  animal  by  artificial  respiration. 

Experiment  7. — Small,  brindled  bitch.  Operation  January  10,  1887.  To 
isolate  loop.  Steps  of  operation  the  same  as  in  Experiment  6.  Czerny's  suture. 
Twenty  minutes  required  for  the  loop  suture,  and  fifteen  minutes  for  the  con- 
tinuity suture.  One  hour  and  fifteen  minutes  for  the  entire  operation.  Dog- 
ceased  breathing  as  abdomen  was  being  sewed.  Heart  continued  to  beat. 
Artificial  respiration  employed  for  thirty  minutes  before  active  respiration 
became  reestablished. 

January  11.  Dog  still  alive,  and  able  to  walk.    No  vomiting.    Natural  stool. 

12^.  Found  dead.  Autopsy:  Local  peritonitis  referable  to  sutures.  Each 
stitch  occupies  a  focus  of  pus.  Conclude  that  the  silk  used  may  not  have 
been  sufficiently  disinfected,  for  it  was  not  placed  in  the  sublimate  solution 
until  just  before  the  operation  was  undertaken. 

Experiment  8. — Rather  large,  black  and  white  dog.  Operation  January 
8,  1887.  To  isolate  loop  of  intestine.  Irrigation  with  solution  of  corrosive 
sublimate,  1:10,000.  Glass  clamps.  Suture,  catgut;  Hagedorn's  needles. 
Three  rows  of  Lembert's  stitches.  Many  of  the  stitches  tore  out,  and  had  to 
be  reapplied.  Some,  certainly,  perforated  into  lumen  of  gut.  Expressed 
myself  at  the  time  as  being  dissatisfied  with  the  operation.  Felt  sure  that  the 
dog  would  die,  because  I  thought  that  I  had  been  unusually  clumsy  in  my 
technique. 

January  9.  Dog  lively,  and  seems  well. 

25£A.  Dog  has  not  had  a  bad  symptom  since  the  operation. 

February  1.  Not  so  well. 

3d  Refuses  both  meat  and  drink. 

9th.  Dog  is  evidently  starving  to  death.  Reopen  abdomen,  find  many  and 
very  strong  adhesions.  Both  circular  sutures  firm.  The  isolated  loop  is  dis- 
tended to  about  the  size  of  an  inflated  human  transverse  colon,  with  focal- 
smelling,  thick,  brownish-gray  fluid ;  and  its  wall  is  two  or  three  times  as 
thick  as  normal. 

That  these  cases  (Group  I.)  testify  to  the  defectiveness  of  my  technique, 
I  am  eager  to  admit ;  at  the  same  time  I  find  no  proof  that  the  method 
of  any  one  else  has  been  otherwise  than  very  uncertain.    The  single- 


444      HALSTED,  CIRCULAR  SUTURE   OF  INTESTINE. 

resection  experiments  (Group  I.),  although  they  might  be  called  suc- 
cessful, must,  when  contrasted  with  Experiment  A,  and  with  those  which 
are  to  follow  (Group  II.),  be  regarded  with  dissatisfaction.  The  serious 
adhesions  which  were  present  in  the  former  cases,  indicate  an  imperfect 
method ;  and  in  the  absence  of  any  such  in  the  latter  lies  the  promise  of 
a  better  technique.  .  The  most  favorable  accounts  of  single  resections  on 
dogs  come  from  Madelung  and  Rydygier.  The  one  reports  nine,  and  the 
other  ten  experiments  as  successful. 

Studying  Rydygier's  cases,1  I  observe  that,  whenever  an  autopsy  was 
made,  extensive  adhesions  were  found,  as  is  evident  by  the  following 
quotations : 

"Experiment  1.  *  *  *  The  site  of  resection  is  bound  by  adhesions  to  the  contiguous  loops  of  intes- 
tine." 

"Experiment  2.  *  *  *  The  intestinal  loops  which  lie  near  to  the  site  of  resection,  are  bound  together 
by  adhesions." 

"  Experiment  3.  *  *  *  The  site  of  resection,  which  is  completely  healed,  is  bound  by  adhesions  to  the 
abdominal  wound  ;  furthermore,  several  loops  of  intestine  are  glued  together." 

"Experiment  4.  *  *  *  The  abdominal  wound  is  healed,  and  the  omentum  is  adherent  to  it.  Several 
loops  of  intestine  are  matted  together  about  the  site  of  the  resection,  and  in  separating  them  the  intes- 
tinal suture  gives  way  to  a  slight  extent." 

Furthermore,  of  the  six  unautopsied  animals,  not  one,  perhaps,  had 
lived  long  enough,  at  the  time  of  Rydygier's  writing,  to  justify  the  belief 
that  death  from  adhesions  might  not  ultimately  have  ensued. 

Rydygier's  tenth  experiment  was  made  September  7th,  and  on  the  10th 
of  October  of  the  same  year  his  article  appeared. 

We  cannot  analyze  Madelung's  work  on  dogs,  because  he  has  not 
thought  it  worth  while  to  detail  his  experiments.  In  recommendation 
of  his  " Knorpelplattennaht,"  he  says:2 

"I  wish  to  say  in  its  favor,  that  in  the  nine  experiments  on  animals  in  which 
I  performed  in  this  manner  circular  intestinal  and  gastric  resection,  an  imme- 
diate and  complete  union  took  place  in  every  instance.  In  no  instance  did 
escape  of  feces  take  place.  I  do  not  think  it  worth  while  to  give  a  detailed 
account  of  these  experiments,  which  were  instructive  enough  to  me." 

I  have  no  doubt  that  the  results  of  the  gentlemen  just  quoted,  were 
much  better  than  I  could  have  obtained  by  their  methods  as  they  describe 
them ;  for  each,  with  his  great  experience,  must  have  acquired  an  art  of 
sewing  which,  from  a  scientific  standpoint,  is  not  sufficiently  precise  to  be 
communicated  to  others. 

To  read  Kaiser's3  experiments  is  to  become  convinced  of  the  uncer- 
tainty with  which,  in  the  taking  of  stitches,  he  must  contend  who  does 
not  avail  himself  of  the  guidance  offered  by  the  submucosa. 

"Experiment  1.  ***  Autopsy  reveals  a  silk  thread  projecting  into  the  lumen  of  the  intestine, 
about  which  there  is  a  small  lens-like  depression."  ' 

"Experiment  3.  *  *  *  On  the  stomach,  on  its  inner  side,  one  recognizes  the  cicatrix  iu  the  slightly 
elevated  ridge.  On  the  duodenum,  very  close  to  the  cicatrix,  are  two  silk  ligatures  which  lead  into 
two  small  pouches." 

The  fact  that  both  of  these  experiments  succeeded  notwithstanding 
that,  in  each,  stitches  had  been  passed  into  the  lumen  of  the  intestine  or 

1  Rydygier  :  Berlin,  klin.  Wochenschr.,  1881,  p.  593.  2  Madelung,  1.  c,  p.  323. 

*  Kaiser  :  Beitrage  zur  Operativen  Chirurgie  (Czerny),  1878,  p.  142. 


HALSTED,  CIRCULAR 


SUTURE 


OF  INTESTINE. 


of  the  stomach,  makes  it  more  than  probable  that  Kaiser  is  not  the  only 
one  who,  in  spite  of  an  imperfect  technique,  has  had  good  results. 

The  experiments  of  miue  to  which  I  particularly  wish  to  invite  atten- 
tion are  those  of  Group  II.  In  all  of  the  operations  of  this  group  the 
plain-quilt  submucosa  stitches  were  employed  for  the  complete  row  ;  and, 
in  most  of  them  a  few  presection  buried-knot  (vide  Fig.  2  and  Group 
III.)  quilt  stitches  were  taken  in  addition. 

Group  II.    Plain-quilt  Submucosa  Stitches. 

Experiment  1. — Large,  black-and-tan  dog.  Operation  January  25,  1887. 
Double  circular  suture :  to  reverse  about  one  foot  of  intestine.1  Irrigation 
with  solution  of  corrosive  sublimate,  1 : 10,000.  Glass -slide  clamps.  Suture. 
Seven  presection  stitches  in  incomplete  first  row ;  and  ten  plain-quilt  (post- 
section)  stitches  in  second  row.  Intestine  well  washed  with  warm  water  just 
before  being  replaced. 

January  26.  Dog  wags  his  tail,  but,  otherwise,  rather  quiet. 

February  1.  Very  lively,  and  seems  perfectly  well. 

8th.  Dog  continues  to  be  well. 

27th  (about  five  weeks  after  the  operation).  Has  been  losing  appetite  and 
•spirits  for  a  week  or  more.  Killed.  Autopsy :  Both  circular  sutures  perfectly 
healed — adhesions  not  nearly  so  extensive  as  in  Experiment  8  (Group  L),  the 
successful  "Etagennaht "  loop  case.  The  further  description  of  the  autopsy 
is  reserved  for  another  purpose. 

Experiment  2. — Large,  black  Xewfoundland  bitch.  Operation  February 
28th.  Double  circular  suture :  to  reverse  one  foot  of  intestine.  Very  free 
irrigation  with  solution  of  corrosive  sublimate  of  uncertain  strength — prob- 
ably 1  :  1000.  Suture,  sublimate  silk.  Five  presection  stitches — one  com- 
plete row  of  plain-quilt  postsection  stitches. 

March  2.  Dog  found  dead.  Autopsy,  by  Dr.  Mall :  Absolutely  no  perito- 
nitis and  no  adhesions.  Lines  of  suture  perfectly  firm.  Unmistakable  evi- 
dences of  too  much  irrigation,  and  with  a  too  strong  solution  of  corrosive 
sublimate.  Ulcers  of  mucous  membrane  of  stomach.  Subperitoneal  hemor- 
rhages— particularly  over  bladder,  etc. 

Experiment  3. — Very  large,  black  Newfoundland  dog.  Operation  March 
4,  1887.  Double  circular  suture  :  to  reverse  one  foot  of  intestine.  Irrigation 
with  solution  of  corrosive  sublimate,  1 :  20,000.  Considerable  contamination 
of  sutures  and  intestines  with  feces  throughout  the  operation. 

March  6.  Dog  so  savage  that  no  one  can  enter  the  room  in  which  he  is 
confined. 

April  1.  Dog  has  not  had  a  bad  symptom  since  the  operation. 

May '7.  Killed.  Autopsy  made  by  Dr.  Welch,  who  writes  me  that  the  dog 
"was  very  weak  and  emaciated,  and  could  not  have  lived  much  longer.  We 
found  the  same  condition  of  things  as  in  the  other  case.2  There  was  a  mass 
of  solid  material,  made  up  mostly  of  bits  of  straw,  wood,  and  hair,  which 
formed  a  firm  impaction,  beginning  above  and  extending  an  equal  distance 
below  the  upper  suture,  but  not  reaching  down  more  than  halfway  between 
the  two  sutures.  The  intestine  was  much  distended  at  the  seat  of  the  impac- 
tion and  also,  although  to  a  less  extent,  above  the  impaction.  There  were 
very  few  adhesions.  The  peritoneum  was  clean,  and  the  intestine  beautifully 
healed  at  the  site  of  the  sutures — the  inner  surface  being  perfectly  smooth." 

Experiment  4. — Moderately  large,  yellow  dog.  Operation  February  19, 
1887.  Single  circular  resection  and  circular  suture.  Irrigation  with  solution 
of  corrosive  sublimate,  1  :  20,000.    Suture,  sublimate  silk.    Six  presection 


i  Vide  Experiment  C. 


2  Experiment  1,  Group  II. 


446      HALSTED,  CIRCULAR   SUTURE   OF  INTESTINE. 


buried-knot  quilt  stitches,  and  one  complete  row  of  postsection  plain-quilt 
stitches. 

February  20.  Dog  moderately  lively. 

March  11.  Perfectly  well.  Killed  to  make  injection  of  liver.  Autopsy  : 
Suture  perfectly  healed.    A  very  few  slight  adhesions. 

Experiment  5.— Large,  white  dog.  Operation  March  5,  1887.  Single 
circular  resection  and  circular  suture.  1.  Application  of  seven  presection 
buried-knot  quilt  sutures.  2.  Ligation  of  vessels  by  circumvection  ("Um- 
stechung").  3.  Application  of  clamps.  4.  Section  of  intestine  very  close 
to  presection  stitches.  5.  Tying  of  presection  stitches.  6.  Application  of 
plain-quilt  stitches  (rather  too  far  from  cut  edge  of  intestine).  7.  Tying  of 
plain-quilt  stitches. 

March  11.  Dog  seems  perfectly  well.  Killed  to  make  injection  of  vessels 
of  circular  suture.  Autopsy :  Slight  local  peritonitis  starting  from  a  small 
necrotic  ulcer  (ulcer  has  not  perforated  gut  wall — is  rather  superficial)  very 
near  the  mesenteric  border,  at  line  of  circular  suture.  This  ulcer  proceeded 
undoubtedly  from  strangulation  where  the  stitches  (both  rows)  were  closest 
together. 

Experiment  6. — Large,  yellow  dog.  Operation  March  8,  1887.  Single 
circular  resection  and  circular  suture.  Intestine  cut  very  close  to  presection 
stitches.  Postsection  plain-quilt  sutures  applied  nearer  than  usual  to  the  pre- 
section stitches. 

March  25.  Dog  has  had  no  bad  symptoms  since  the  operation.  Killed. 
Autopsy :  No  adhesions,  except  a  very  delicate  attachment  of  omentum  to 
line  of  suture,  anteriorly. 

Experiment  7. — Small,  shaggy,  yellow  dog.  Operation  March  8,  1887. 
Single  circular  resection  and  circular  suture.  A  few  presection  stitches  :  one- 
complete  row  of  postsection  plain-quilt  stitches. 

March  14.  Dog  has  made  an  uninterrupted  recovery.  Used  for  a  second 
experiment  for  another  purpose.  Killed.  Autopsy :  No  adhesions.  Circular 
suture  beautifully  healed,  but  so  much  intestinal  wall  had  been  turned  in 
that  some  obstruction  had  been  caused — manifested  by  conical  dilatation  of 
intestine,  and  accumulation  in  it  of  hay,  on  the  proximal  side  of  the  suture. 

This  case  is  one  of  several  which  indicate  that  it  is  not  advisable  to 
make  two  rows  of  stitches  on  small  dogs. 

Experiment  8. — Very  large,  brown  dog.  Operation  March  14,  1887. 
Single  circular  resection  and  circular  suture.  A  few  presection  and  one  com- 
plete row  of  postsection  sutures.  Operation  performed  without  an  assistant, 
and  without  the  employment  of  antiseptics.  No  clamps.  Irrigation  with  a 
solution  of  common  salt,  0.6  per  cent.,  at  37°  Cent. 

March  25.  Dog  has  made  an  uninterrupted  recovery.  Killed.  Autopsy  r 
No  adhesions — not  even  of  omentum  to  the  line  of  the  suture.  A  very  perfect 
result. 

This  operation  was  performed  without  any  antiseptic  precautions,  and 
without  an  assistant ;  and  yet,  as  the  autopsy  showed,  the  result  could 
not  have  been  more  perfect. 

Experiment  9. — Eather  large,  black  and  white  dog.  Operation  March 
18,  1887.  Single  circular  resection  and  circular  suture.  A  few  presection 
and  one  complete  row  of  postsection  stitches.  Even  less  attention  paid  to 
cleanliness  than  in  the  preceding  experiment :  for  the  dog  was  operated  upon 
to  furnish  situations  from  which  to  make  drawings.  About  one  foot  of  intes- 
tine was  exposed  outside  of  the  abdominal  cavity  for  more  than  two  hours; 
and  when  returned  was  very  blue  and  much  swollen.  But  the  sewing  was 
very  carefully  and  satisfactorily  done. 

April  1.  Dog  is  very  lively,  and  seems  well.  Used  by  Dr.  Mall  for  another 


HALSTED,  CIRCULAR  SUTURE 


OF 


INTESTINE. 


447 


operation.  Killed.  Autopsy :  Intestinal  wound  firmly  healed,  but  the  intes- 
tines, at  the  site  of  the  suture,  are  matted  together. 

It  is  not  strange  that  the  intestines  should,  in  this  case,  have  been 
matted  together ;  but  rather  to  be  wondered  at  that,  under  the  circum- 
stances, the  dog  could  have  made  even  such  a  recovery,  indifferent  as  it 
appears  from  our  present  point  of  view. 

Experiment  10. — Large,  black  dog.  Operation  March  17,  1887.  Single 
circular  resection  and  circular  suture.  Operation  without  antiseptics  and 
without  clamps.  Suture.  A  few  presection  and  one  complete  row  of  post- 
section  stitches.  The  silk  was  so  very  old  that  it  broke  often  on  tying,  and 
many  of  the  stitches  had  to  be  retaken.  I  am  quite  sure  that  one — possibly 
two — of  the  stitches  were  passed  into  the  lumen  of  the  gut.  More  than  one 
foot  of  intestine  allowed  to  remain  outside  of  the  abdominal  cavity  for  one 
and  three-quarter  hours.  The  dog  had  tapeworm  and  much  feces  in  his  in- 
testine, so  that  there  was  a  good  opportunity  for  contamination  of  the  wound 
and  of  the  abdominal  cavity.  Very  free  irrigation,  during  and  after  the 
completion  of  the  circular  suture,  with  a  warm  salt  solution — 0.6  per  cent. 
Should  this  case  recover,  I  shall  regard  it  as  very  strong  evidence  in  favor  of 
my  suture. 

April  2.  Dog  lively,  and  apparently  well.  Dr.  Mall  killed  the  dog,  subse- 
quently, and  appended  the  following  to  the  history  :  Autopsy:  "  No  perito- 
nitis. Suture  fully  healed.  A  large  worm  (eustrongylus  gigas),  alive  and 
active,  found  in  the  peritoneal  cavity." 

Experiment  11. — Rather  large,  white  bitch.  Operation  February  1, 1887. 
Single  circular  resection  and  circular  suture.  One  complete  row  of  plain -quilt 
submucosa  stitches  (vide  Fig.  7)  applied  before  and  tied  after  resecting  about 
half  an  inch  of  intestine.  I  found  the  taking  of  these  stitches  very  easy,  but 
to  resect  the  gut  under  them  was  somewhat  troublesome.  The  method,  on 
the  whole,  is  a  moderately  rapid  one — occupying  about  forty  minutes. 

February  2.  Dog  doing  nicely. 

26th.  Dog  perfectly  well.  Killed.  Autopsy :  So  adhesions.  A  most  per- 
fect result. 

It  will  be  observed  that  in  this  (the  foregoing)  case,  as  well  as  in  all 
of  the  following  cases  of  this  group,  the  incomplete  row  of  presection 
stitches  was  omitted ;  and  that  but  one  row  of  stitches  was  employed 
for  the  circular  suture. 

Experiment  12. — Very  large,  olive-brown  dog.  Operation  February  1, 
1887.  Resection  of  two  feet  of  intestine.  I  made,  at  first,  a  circular  suture 
of  Emmert's  stitches  (vide  Fig.  8) ;  then,  being  dissatisfied  with  the  appear- 
ance of  the  suture,  I  again  resected  the  intestine  and  applied  one  complete 
row  of  plain-quilt  stitches. 

February  2.  Dog  convalescent. 

3d.  Dog  lively,  and  apparently  well. 

March  9.  Still  perfectly  well.  Killed.  Autopsy:  No  peritonitis,  and 
absolutely  no  adhesions. 

The  intestinal  wound  had  healed  so  perfectly  that  its  site  was  only 
discovered  after  Dr.  Mall  and  I,  in  search  of  the  suture  line,  had  run 
the  intestine  several  times  through  our  fingers. 

Experiment  13.— Small,  shaggy,  black  dog.  Operation  February  14, 
1887.  Circular  resection  and  circular  suture.  One  complete  row  (eighteen 
stitches)  of  plain-quilt  stitches.  Irrigation  with  tepid  salt  (0.6  per  cent.) 
solution,  and,  sparingly,  while  tying  the  stitches,  with  a  solution  of  corrosive 
sublimate— 1 :  20,000. 


448      HALSTED,  CIECULAR   SUTURE  OF  INTESTINE. 

February  15.  Dog  is  quiet — still  affected  by  morphine. 
lQth.  Dog  is  very  playful. 

March  10.  Perfectly  well.  Killed.  Autopsy:  Circular  suture  perfectly 
healed.    Slight  adhesion  of  the  omentum  to  the  line  of  the  suture. 

Experiment  14. — Very  small,  old,  black  and  tan  bitch.  Operation  Feb- 
ruary 21,  1887.  Circular  resection  and  circular  suture.  One  row  of  plain- 
quilt  presection  sutures  {vide  Fig.  7).  Intestine  very  small;  the  smallest,  I 
think,  that  I  have  ever  sutured. 

March  7.  Dog  has  been  doing  fairly  well  ever  since  the  operation,  but 
has  refused  food  for  a  day  or  two. 

March  9.  Found  dead.  Autopsy:  No  peritonitis.  Near  the  site  of  the 
circular  suture  the  gut  is  found  to  be  much  twisted,  and  bound  in  this  position 
by  adhesions,  in  themselves  very  trivial.  Above  the  twist  the  intestine  is  very 
much  dilated.  Death  from  ileus.  The  suture  is  most  beautifully  healed, 
even  to  mucous  membrane  inclusive. 

Experiment  15. — Large,  brown  and  white  bitch.  Operation  March  3, 
1887.  Circular  resection  and  circular  suture.  One  complete  row  of  plain- 
quilt,  postsection  stitches.  Glass  clamps.  Irrigation  with  1 : 12,000  corrosive 
sublimate  solution. 

March  14.  Dog  has  made  an  uninterrupted  recovery.  Given  to  the  janitor 
for  a  pet. 

June  1.  Dog  perfectly  well. 

Although  there  were  but  fifteen  experiments  in  this  group,  they  in- 
clude eighteen  circular  sutures  of  the  intestine,  all  of  which  were  suc- 
cessful. In  three  instances,  about  one  foot  of  intestine  was  reversed,  and 
a  double  circular  suture  required.  Furthermore,  the  making  of  two 
circular  sutures  at  one  time,  particularly  when  accompanied  with  re- 
versal of  a  portion  of  the  intestine,  increases  more  than  twofold  the 
danger  to  the  animal  operated  upon. 

But  what  chiefly  distinguishes  these  results,  is  the  absence  of  adhesions. 
In  five  of  the  experiments  (2,  7,  8, 11,  and  12)  there  were  absolutely  no 
adhesions ;  nor  were  there  any  such  in  Experiments  6  and  13,  save  the 
slight  ones  between  the  omentum  and  the  face  of  the  line  of  the  suture. 
In  only  one  instance  were  the  intestines  matted  together  as  described  by 
Kydygier  and  other  surgeons,  and  as  seen  by  me  in  so  many  of  my 
earlier  experiments.  They  who  have  attempted  double  circular  resec- 
tion and  double  circular  suture  can  best  appreciate  the  magnitude  of  the 
operation  of  reversing  a  portion  of  the  intestine,  and  can  understand, 
perhaps,  my  great  faith  in  the  suture  which  has  given  such  results. 
Experiments  8,  9,  and  10  were  performed  without  clamps,  without  anti- 
septics— except  for  the  silk,  which  had  been  prepared  in  the  usual  way 
— and  without  especial  attention  to  cleanliness,  save  that  the  intestinal 
wound  was  diligently  washed  with  a  warm  salt  solution  while  the  stitches 
were  being  tied.  It  may  be  asked  wh)r  adhesions  should  be  so  strongly 
objected  to.  Not  so  much  to  the  adhesions  as  such  is  it  objected — 
although  we  have  seen  and  already  called  attention  to  the  fatal  conse- 
quences of  the  obstruction  which  may  attend  them — as  to  the  imperfect 
technique  which  constantly  admits  of  the  matting  together  of  the  intes- 
tines. 


HALSTED,  CIECULAK  SUTURE   OF  INTESTINE. 


449 


Adhesions  of  this  nature  imply  inflammation ;  and  an  inflammation 
of  an  extent  which,  though  it  may  not  usually  prove  disastrous,  is  always 
more  or  less  dangerous.  The  less  extensive  the  inflammation,  the  greater 
the  certainty  that  the  suture  will  hold.  It  cannot,  fairly,  be  urged  that 
time  may  have  swept  away  the  adhesions  in  my  cases,  for  the  autopsies, 
at  which  no  adhesions  at  all  were  found,  were  made  two  (Experiment  2), 
six  (Exj)eriment  7),  eleven  (Experiment  8),  twenty-five  (Experiment  11), 
and  thirty-six  (Experiment  12)  days  after  the  operations. 

It  is  believed  that  the  method  of  operation  adopted  in  the  experi- 
ments of  Group  II.  combats  more  satisfactorily  than  any  hitherto  sug- 
gested the  dangers  which  naturally  attend  suture  of  the  intestine.  The 
great  danger  to  be  apprehended  is,  as  already  mentioned,  the  develop- 
ment of  suppurative  peritonitis  as  the  result  of  the  operation. 

Let  us  consider  for  a  moment  the  various  factors  which  during  or  after 
the  operation  of  intestinal  suture  may  lead  directly  or  indirectly  to  the 
production  of  purulent  peritonitis.  In  judging  of  the  efficacy  of  the 
factors  we  are  guided  by  the  results  of  the  experiments  mentioned  in  the 
beginning  of  this  article. 

In  the  first  place,  whence  may  the  pyogenic  substances  come  which 
are  essential  to  the  production  of  suppurative  peritonitis  ?  Evidently 
either  from  outside  of  the  body  through  the  wound  in  the  abdominal 
wall  or  from  the  intestine  through  the  wound  in  its  coats.  There  is,  of 
course,  no  especial  danger  of  infection  of  the  peritoneal  cavity  from  the 
exterior  in  the  performance  of  enterorrhaphy,  as  compared  with  other 
operations  requiring  laparotomy.  This  is  not  a  danger,  therefore,  which 
needs  any  especial  consideration  in  this  connection  or  which  is  to  be 
regarded  as  serious. 

The  chief  danger  of  infection  of  the  peritoneal  cavity  is  manifestly 
from  the  contents  of  the  intestine,  in  case  they  find  their  way  through 
the  wround  in  the  intestine  or  along  the  lines  of  suture.  There  is  a 
possibility  of  the  escape  of  intestinal  contents  at  the  time  of  the  opera- 
tion, but  this  is  a  danger  which  can  be  readily  guarded  against  and 
one  which  is  much  less  likely  to  be  attended  by  serious  results  than  the 
escape  of  intestinal  contents  into  the  peritoneum  subsequent  to  the 
operation.  Probably  too  much  importance  has  been  attached  to  the  use 
of  antiseptic  solutions  for  irrigation  in  intestinal  resection  (vide  Experi- 
ments 8,  9,  10,  and  13). 

Although  in  performing  enterorrhaphy  on  the  human  being  I  should 
be  unwilling  to  discard  what  seems  undoubtedly  to  be  an  additional 
precaution,  I  should,  in  the  light  of  my  experiments,  and  of  several  of 
my  operations,  hesitate  to  employ  solutions  as  strong  as  those  commonly 
advised. 

We  are  brought,  therefore,  to  the  conclusion  that  the  chief  danger  of 
infection  of  the  peritoneum  is  from  the  passage  of  the  intestinal  contents 

NO.  CLXXXVIII.—  OCTOBER,  18S7.  29 


450      HALSTED,  CIRCULAR   SUTURE   OF  INTESTINE. 


(bacteria)  into  the  peritoneal  cavity  subsequent  to  the  operation.  The 
conditions  which  may  lead  to  this  unfortunate  occurrence  are  1,  failure 
to  close  completely  and  firmly  the  wound  of  the  intestine ;  2,  penetration 
of  the  intestinal  lumen  by  one  or  more  sutures ;  3,  giving  way  of  the 
sutures;  4,  ulceration  or  sloughing  of  the  intestine  at  the  site  of  suture. 

In  order  to  bring  about  complete  and  firm  closure  of  the  abnormal 
opening  into  the  intestine  it  has  been  customary  to  make  several  series 
of  sutures  of  the  intestine  one  over  the  other  in  the  form  of  the  so-called 
"  Etagennaht."  In  this  way  a  considerable  extent  of  the  intestinal  wall 
is  folded  in,  the  circulation  of  which  is  greatly  impeded.  There  are 
especial  dangers  which  attend  the  folding  in  of  an  unnecessarily  large 
amount  of  intestinal  wall,  for,  on  the  one  hand,  this  increases  the  extent 
of  tissue  which  undergoes  sloughing  and  thus  increases  the  danger  of 
infection,  and,  on  the  other  hand,  the  flange  formed  by  the  folds  pro- 
jecting into  the  intestinal  lumen  is  an  obstacle  to  the  passage  downward 
of  the  feces,  which,  accumulating  at  and  above  the  site  of  suture,  in- 
crease the  tension  upon  the  sutures  and  endanger  their  separation. 

Experiments  will  subsequently  be  described  which  show  that  these 
dangers  are  not  imaginary  but  real.  A  sufficiently  firm  closure  of  the 
wound  in  the  intestine  with  much  less  danger  from  the  sources  men- 
tioned is  accomplished  by  the  method  adopted  in  the  experiments  of 
Group  II.,  and  which  will  be  described  subsequently. 

Although  experiments  have  already  been  cited  which  show  the  possi- 
bility of  recovery  even  when  stitches  in  the  final  row  of  sutures  have 
penetrated  the  lumen  of  the  intestine,  nevertheless,  it  is  plain  that  this 
penetration  of  the  intestinal  lumen  is  an  accident  which  may  lead  to 
serious  consequences,  and  it  is  to  be  carefully  avoided.  While  it  has 
been  the  aim  of  previous  operators  to  avoid  this  accident,  no  definite 
rules  have  been  laid  down  by  which  this  is  to  be  accomplished.  I  wish, 
therefore,  in  this  connection  to  lay  especial  emphasis  upon  the  impor- 
tance of  appreciating,  as  can  be  done  in  the  manner  already  described, 
the  moment  when  the  point  of  the  needle  comes  into  contact  with  the 
submucous  coat  of  the  intestine.  By  observing  this,  it  is  within  our 
power  so  to  guide  the  needle  that,  while  including  a  bit  of  submucous 
tissue,  it  does  not  penetrate  the  mucous  coat. 

Of  no  less  importance  in  guarding  against  the  third  danger  of  perito- 
neal infection  from  intestineal  contents,  is  care  that  each  stitch  in  the  final 
row  shall  include  a  bit  of  submucous  tissue.  Utterly  misleading  is  the 
usual  direction,  that  the  stitches  shall  include  only  serous  membrane,  or 
even  serous  membrane  and  muscular  coat.  Experiment  A  was  given 
precedence  in  the  list  of  the  experiments  described  in  this  article,  in 
order  to  give  prominence  to  the  fallacious  character  of  this  direction. 
Any  one,  by  a  simple  experiment,  can  convince  himself  how  frail  is  the 
hold  of  sutures  which  include  only  serosa  and  muscularis.   I  am  inclined 


HALSTED,  CIECULAE   SUTURE  OF  INTESTINE.  451 

to  regard  perforation  of  the  gut-wall,  on  the  one  hand,  and  the  tearing 
out  of  stitches,  on  the  other,  as  the  leading  factors  in  the  production  of 
the  peritonitis  which  has  brought  about  the  fatal  issue  in  many  cases  of 
intestinal  suture. 

The  occurrence  of  ulceration  or  necrosis  of  the  intestinal  wall  at  the 
seat  of  suture,  is  a  danger  which  is  twofold  in  its  action.  It  renders 
possible  the  escape  of  intestinal  contents,  and  it  affords  a  soil  suitable 
for  the  lodgement  and  growth  of  bacteria.  How  important  is  the 
latter  factor,  has  been  made  apparent  by  the  experiments  of  Grawitz 
previously  cited.  Especial  dangers  attend  necrosis  of  the  serous  and 
subjacent  coats  of  the  intestine,  even  when  the  necrosis  does  not  extend 
to  the  mucous  membrane;  for,  doubtless,  intestinal  bacteria  which,  other- 
wise would  prove  harmless,  may  reach  the  diseased  tissue  and  find  suit- 
able conditions  for  their  development. 

We  must  not  forget  that  the  predisposition  to  infectious  inflammation 
is  necessarily  always  present  in  circular  suture  of  the  intestine,  and  lies 
in  the  interference  with  the  circulation  which  the  suture  causes,  but  it 
should  be  our  aim  to  reduce  this  predisposition  to  a  minimum.  The 
circular  suture  disturbs  the  circulation  both  directly  and  indirectly  : 
directly,  in  so  far  as  the  stitches  produce  constriction  of  the  tissues  which 
they  include ;  and  indirectly,  in  that  it  bends  a  portion  of  the  intestinal 
wall  at  right  angles  to  its  original  long  axis.  To  these  causes  of  disturb- 
ance of  the  circulation  is  to  be  added  the  pressure  from  above  of  the 
contents  of  the  intestine  upon  the  flange  which  is  projected  into  the 
lumen  in  the  form  of  the  involuted  intestinal  wall.  I  am  inclined  to 
believe  that  this  projecting  flange  acts,  perhaps,  less  as  a  cause  of  intes- 
tinal obstruction  than  as  a  factor  predisposing  to  the  formation  of 
adhesions,  which,  to  the  best  of  my  knowledge,  have  seldom  been  absent 
in  the  obstruction  cases.  It  has  seemed  to  me  that  these  adhesions  have 
been  particularly  luxuriant  when  too  much  tissue  has  been  turned  in  by 
the  circular  suture. 

The  results  which  were  obtained  in  the  series  of  experiments  consti- 
tuting Group  II.,  furnish  a  sufficient  answer  to  the  plea  that  it  is  desira- 
ble to  turn  in  over  a  large  extent  the  edges  of  the  intestinal  wound,  in 
order  to  bring  as  much  of  the  peritoneal  surfaces  as  possible  into  contact. 
As  has  been  shown,  a  sufficiently  extensive  adaptation  of  peritoneal 
surfaces  to  each  other  can  be  accomplished  without  inverting  an  exces- 
sive amount  of  intestine,  and  thus  with  less  impairment  of  the  vitality 
of  the  intestine,  and  consequently  less  predisposition  to  peritonitis. 

If  the  turning  in  of  tissue  predisposes  to  too  extensive  inflammation, 
perhaps  the  greatest  danger  of  turning  in  too  much  is  not  that  the  flap 
may  play  the  part  of  a  stricture,  but  that  the  circulation  at  the  site  of 
the  suture  may  be  so  much  interfered  with  that  union  will  not  take  place. 

Experiments  G  and  H  were  made  partly  to  determine  if  this  were  so, 


452      HALSTED,  CIRCULAR   SUTURE   OF  INTESTINE. 


and  partly  to  assist  in  establishing  my  belief  that  one  could  not,  with 
safety,  invert  as  much  tissue  in  small  as  in  large  dogs. 

Experiment  G. — Very  small  brown  bitch.  Operation  March  5, 1887.  To 
employ  two  rows  of  quilt  stitches  in  suturing  the  intestine  of  a  very  small 
animal. 

March  9.  Died.    Autopsy:  Gangrene  of  inverted  edges.    No  union. 

Experiment  H. — Very  small,  black  and  tan  terrier  bitch.  Operation 
March  7, 1887.  To  employ  two  rows  of  quilt  stitches  in  suturing  the  intestine 
of  a  very  small  animal.  Intestine  so  small  that,  after  the  second  row  of 
stitches  was  tied,  the  gut  at  the  site  of  the  suture  looked  quite  white,  especi- 
ally along  the  convex  border. 

March  11.  Dog  not  well.  Killed.  Autopsy:  Gangrene  of  flap,  as  expected. 
Purulent  peritonitis. 

If  two  rows  of  stitches  are  so  dangerous  in  very  small  dogs,  why  use 
presection  stitches  even  in  large  dogs  ? 

This  question  leads  us  to  the  consideration  of  the  technique. 

Technique. — When  the  gut  has  been  completely  divided  there  ensues, 
immediately,  a  spasm  of  the  circular  muscle  fibres  nearest  the  cut  edges, 
which  inverts  the  mucous  membrane,  and  almost  closes  the  newly  made 
intestinal  orifices.  The  spasm  of  these  fibres  lasts  but  a  few  seconds  :  it 
is  succeeded  by  a  relaxation  of  the  same,  and  by  a  contraction  of  the 
adjacent  circular  fibres ;  and  now  the  mucous  membrane  is  rolled  out.  It 
is  exceedingly  troublesome  to  take  the  stitches  properly  when  the  mucous 
membrane  is  thus  everted.  To  relieve  myself  of  this  annoyance,  I 
devised  and  tested  various  presection  stitches,  and,  finally,  adopted  the 
one  represented  in  Fig.  2. 


Fig.  2. 


Presection,  buried-knot  quilt  half-stitches. 


To  distinguish  it  from  the  other  forms  of  quilt  stitch,  I  have  called  it 
the  buried-knot  quilt  stitch. 

The  four  threads,  two  from  each  side,  are  tied  at  one  time,  and  the 
knot  becomes  buried  in  the  folds  which  have  been  raised  up  thereby. 


HALSTED.  CIRCULAR   SUTURE   OF  INTESTINE. 


453 


From  five  to  seven  presection  stitches — ten  to  fourteen  half-stitches — are 
taken ;  two  of  these  are  at  the  mesenteric  border,  one  on  each  side,  and 
just  at  the  attachment  of  the  mesentery.  The  needle  is  introduced  on  a 
line  with  one  of  the  radii  (vide  Fig.  1,  a)  of  a  transverse  section  of  the 
intestine,  and  pressed  upon  gently  by  the  pulp  of  one  finger  until  the 
resistance  offered  by  the  submucosa  is  encountered ;  it  is  then  tilted  (vide 
Fig.  1,  b)  through  ninety  degrees,  or  until  about  parallel  with  the  long 
axis  of  the  gut,  pressed  on  with  a  little  more  force  than  before,  tilted  still 
further,  and,  finally,  passed  out.  It  is  reintroduced  almost,  but  not  pre- 
cisely, where  it  emerged  (vide  Fig.  2),  passed  through  in  the  same  manner 
as  before,  but  in  the  opposite  direction,  and  its  thread  divided.  The 
threads  of  the  half-stitches  from  both  sides,  when  straightened  out,  natu- 
rally cross  each  other,  and  lie  upon  the  portion  of  intestine  to  be  resected. 
There  is  an  opportunity  for  the  exercise  of  some  discretion  in  the  selec- 
tion of  a  spot  on  the  mesenteric  border  for  the  introduction  of  the  first 
stitch.  The  vessels  distributed  to  the  intestine  are  ensheathed  in  more 
or  less  fat,  usually  in  enough  to  make  the  mesenteric  border  obscure 
except  at  certain  places  between  vessels  which  are  rather  far  apart 
These  places  are  often  entirely  free  from  fat  and,  if  the  mesentery  be  not 
pulled  upon,  are  concave. 

Fig  3.. 


Introduction  of  needle  into  concavity,  free  from  fat,  in  taking  t he  first  nresectioif  stitch. 

At  the  bottom  ot  any  one  of  these  little  concavities  (vide  Fig.  3)  the 
needle  can  be  introduced  with  greater  precision  than  it  could  be  at  a 
point  where  fat  obscures  the  mesenteric  border.  The  first  presection 
stitch  (half-stitch),  so  taken,  can  be  seen  through  the  mesentery,  and 


454      HALSTED,  CIKCULAE   SUTURE   OF  INTESTINE. 


serves  as  a  guide  for  the  taking  of  the  corresponding  stitch  (half-stitch) 
on  the  other  side. 

I  sew  with  what  are  called  milliner's  needles.  These  needles  differ 
from  the  ordinary  cambric  needles,  only  in  that  they  are  disproportion- 
ately long,  and,  hence,  easier  to  handle.  Nos.  9  and  10  are  good  sizes 
for  the  purpose.  Finer  sizes  cannot  be  threaded  easily.  Black  silk  is 
preferable  to  white  because  it  contrasts  more  strongly  with  the  parts  to 
be  sewed.  The  silk  was  prepared  by  soaking  it — on  the  spool — in  a 
solution  of  corrosive  sublimate,  1 : 1000. 

When  all  the  presection  stitches  have  been  introduced,  the  vessels  of 
the  part  to  be  resected  are  ligated  (vide  Fig.  2,  X)  by  circumvection  with 
one  of  the  threaded  milliner's  needles.  Then  the  intestine  is  divided  as 
close  as  possible  to  the  presection  stitches  (vide  Fig.  4).    It  is  better  to 

Fig.  4. 


.  Intestine  divided  close  to  presection,  buried-knot  half  stitches. 

make  a  circular  division  of  the  wall  of  the  intestine  than  to  cut  through 
both  walls  at  once.  By  cutting  rather  rapidly  one  can  take  advantage 
of  the  first  muscular  contraction,  and  can  complete  this  part  of  the 
operation  before  eversion  of  the  mucous  membrane  has  taken  place. 
The  presection  stitches  being  tied,  the  eversion  of  the  mucous  membrane 
is  prevented  and  the  way  prepared  for  the  application  of  the  complete 
row  of  what  may  be  called  plain-quilt  stitches  (vide  Fig.  5). 

Fig.  5. 


Presection,  buried-knot  stitches  tied  ;  plain-quilt,  post-section  stitches  introduced. 

The  plain-quilt  stitches  include,  like  the  presection  stitches,  threads 
of  the  submucosa,  and  should  be  placed  a  little  nearer  to  the  cut  edges 
than  Figs.  5  and  6  would  lead  us  to  suppose.  They  should  all  be 
applied  before  a  single  one  is  tied.  It  is  impossible  to  preserve  a  straight 
line  of  application  if  each  stitch  be  tied  as  it  is  taken — the  tendency 
being  to  depart,  in  an  outward  direction,  more  and  more  from  the 


HALSTED,   CIRCULAR  SUTURE    OF   INTESTINE.  455 

straight  line.  The  distance  from  each  other  at  which  the  stitches  should 
be  taken  cannot  be  given  at  once  for  all  of  them — so  much  depends 
upon  the  spasm  of  the  circular  muscle  fibres  along  the  line  of,  and 
caused  by  the  taking  of  the  stitches.  The  contraction  does  not,  as  a 
rule,  supervene  until  several  stitches  have  beeu  taken ;  but,  once  set  up, 
it  exteuds  in  a  circle  in  advance  of  the  stitches,  and  must  be  taken  into 
consideration  in  the  application  of  them.  Before  the  last  stitches  have 
been  applied  the  muscular  tissue  concerned  is,  frequently,  no  longer  able 
to  respond  to  the  stimulus  of  stitch-taking,  and  the  intestine  assumes  its 
natural  size.  Daring  the  period  of  muscular  contraction  the  stitches 
must  be  applied  very  close  to  one  another — perhaps  one  to  one  and  one- 
half  millimetres  apart — but  before  and  after  this  contraction  an  interval 
of  two  to  two  and  one-half  millimetres  may  be  left  between  them.  The 
wall  of  the  gut  rolls  in  of  itself  as  the  stitches  are  tied  (vide  Fig.  6), 


and  the  entire  operation  can  be  conveniently  performed  without  an 
assistant.  The  threads  must  not  be  drawn  so  tightly  in  tying  as  to  make 
the  tissue  included  in  the  stitch  look  very  anaemic. 

In  five  of  my  operations  (Experiments,  11,  12,  13,  14,  15,  Group  II.) 
the  incomplete  row  of  presection  stitches  was  not  employed ;  and, 
although  the  results  justify  the  belief  that  it  may  with  safety  be  omitted, 
the  operation  is  so  greatly  facilitated  by  its  use  that  I  should  be  sorry, 
without  good  reason,  to  discard  it. 

In  no  instance  was  a  triangular  piece  of  mesentery  exsected ;  nor 
did  I  ever  sew  together  the  edges  of  the  rent  which  was  always  made  in 
the  mesentery,  for  fear  of  including  vessels  which  might  contribute  to 
the  blood  supply  of  the  sutured  parts. 

Irrigation. — The  fluid  used  for  irrigation,  if  neither  too  strong  nor 
too  hot,  seemed  to  have  little  or  no  influence  upon  the  results.  A  solu- 
tion of  corrosive  sublimate — 1 :  20,000 — was  the  one  commonly  em- 
ployed, and  I  should  prefer  a  weaker  (1 :  30,000  to  1  :  40,000)  solution 
to  a  stronger. 

We  had  the  opportunity,  repeatedly,  to  observe  the  immediate  bad 
effects  on  the  intestine  of  solutions  hotter  than  38 0  Centigrade  ;  and  ulti- 
mately I  became  partial  to  cold  or  slightly  tepid  solutions  for  irrigation, 


Fig.  6. 


Intestine  after  all  but  four  of  the  plain-quilt  stitches  have  been  tied. 


456      HALSTED,  CIECULAK  SUTURE  OF  INTESTINE. 


because,  with  the  use  of  them,  the  wall  of  the  intestine  did  not  become 
so  much  swollen,  and  the  stitches  could,  therefore,  be  applied  wTith 
greater  precision. 

I  was  always  especially  careful  to  have  the  wound  freely  irrigated 
during  the  tying  of  each  knot,  and  thus  precluded  the  possibility  of 
imprisoning  foreign  matter  between  the  opposed  peritoneal  surfaces. 

Clamps. — The  intestine  was  usually  clamped  with  glass  microscopical 
slides  of  the  English  pattern ;  first  made  to  embrace  the  gut,  they  were 
then  tied  together  about  their  middle  by  a  disinfected  string ;  lastly,  a 
short  piece  of  rubber-tubing  was  introduced,  on  the  stretch,  between  the 
converging  ends  of  the  slides ;  and,  by  slipping  the  tubing  toward  or 
away  from  the  string,  the  pressure  exercised  by  the  clamp  could  be 
diminished  or  increased.  Aside  from  its  simplicity  and  the  readiness 
with  which  it  can  be  applied,  the  clamp  has,  in  addition,  this  in  its 
favor,  that  through  its  glass  blades  the  state  of  the  circulation  in  the 
intestinal  wall  may  be  watched. 

Abdominal  Wound. — The  incision  was  always,  save  once,  made  in 
the  linea  alba,  and  as  near  to  the  pubes  as  practicable.  If  it  was  car- 
ried too  far  in  the  direction  of  the  xiphoid  cartilage,  we  were  annoyed 
by  the  protrusion  of  a  fatty  flap  covered  by  peritoneum,  which  seemed 
to  spring  from  the  posterior  surface  of  the  lower  piece  of  the  sternum 
and  from  the  upper  part  of  the  inner  surface  of  the  anterior  abdominal 
wall. 

Before  cutting  through  the  peritoneum  we  covered  the  dog  wTith 
two  large  disinfected  towels  (a  procedure  suggested  by  Dr.  Mall),  and 
stitched  them  to  the  edges  of  the  abdominal  wound  and,  above  and 
below  it,  to  each  other. 

The  abdominal  wound  was  closed  usually  with  two  rows  of  sutures. 
The  first  row,  made  with  interrupted  stitches  of  silkworm  gut,  included 
everything  but  the  skin.  The  cut  edges  of  skin  were  then  brought 
loosely  together  by  a  continuous  suture  taken  from  its  under  surface  and 
from  the  underlying  loose  connective  tissue.  The  wounds  were  dressed 
with  horsehair  taken  from  a  corrosive  sublimate  solution,  1 : 1000,  and 
were  bandaged  with  crinoline. 

Preparation  and  Care  of  the  Dogs. — Only  one  of  the  dogs  oper- 
ated upon  (Exp.  3,  Group  II.)  was  dieted  before  the  operation,  or 
isolated  after  it.  The  dogs  were  frequently  fed  on  the  day  of  the  oper- 
ation, and  were  always  allowed  to  run  about,  all  together  in  a  large 
room,  as  soon  after  it  as  they  might  be  inclined.  Milk  was  given  to 
them  as  soon  as  ihef  would  take  it,  but  solid  food  was  withheld  for 
about  one  week. 

Anaesthetics. — Morphine,  hypodermatically  (gi-siv  of  a  five  per 
cent.,  solution),  followed  by  a  few  inhalations  of  ether. 

Neither  Neuber's  intestinal  tubes  nor  any  other  similar  contrivances 


HALSTED,   CIRCULAR   SUTURE    OF   INTESTINE.  457 


were  made  use  of  to  simplify  the  performance  of  circular  suture  of  the 
intestine;  because,  1,  they  were  not  believed  to  be  necessary  ;  and  2,  it 
was  thought  that  they  would  increase  the  danger  of  the  operation. 

The  employment  of  an  incomplete  row  of  buried-knot  presection 
stitches  facilitates  the  application  of  the  subsequent  complete  row  quite 
as  much  as  does  the  use  of  the  Neuber's  tube.  Furthermore,  when  a 
Neuber's  tube  is  used,  an  incomplete  row  of  post-section  stitches  must 
be  taken ;  and,  as  we  have  repeatedly  said,  the  application  of  first  row 
postsection  stitches  is  troublesome,  whereas  it  is  easy  to  apply  presection 
stitches. 

I  believe  that  when  the  circular  suture  is  made  over  a  tube  of  any 
kind  the  circulation  in  the  immediate  neighborhood  of  and  along  the 
line  of  suture  is  additionally  obstructed.  And  should  the  tube  slip  to 
the  slightest  extent  out  of  place,  or  soften  too  quickly,  the  circular 
intestinal  wound  may  leak  ;  for  I  have  repeatedly  observed  that  a  suture 
which  answered  the  purpose  over  a  tube  failed  to  close  the  wound  suf- 
ficiently when  the  tube  was  removed. 

The  Preparation  and  Preservation  of  the  Needles. — Made- 
lung  and  other  surgeons  have  called  attention  to  the  fact  that,  in  order 
to  save  time  at  the  operation,  it  is  well  to  have  the  needles  threaded 
beforehand,  and  hence,  to  have  a  method  of  protecting  the  disinfected, 
threaded  needles  permanently  from  rusting.  Madelung  suggests  keep- 
ing them  in  alcohol.  I  have  tried,  among  other  fluids,  glycerine  and 
alcohol,  and  found  both  of  them  too  hygroscopic  for  the  purpose.  The 
difficulties  seem  to  be  most  readily  met  by  the  adoption  of  an  antiseptic 
oil.  I  have  used  with  satisfaction  the  oil  of  juniper  berries.  It  is, 
furthermore,  necessary  to  have  a  means  of  supporting  the  needles  in 
the  oil,  and  above  the  water  with  which  the  oil  is,  from  the  picking 
up  of  the  needles  with  wet  fingers  or  wet  forceps,  sooner  or  later,  cer- 
tain to  become  contaminated.  It  is  not  enough  to  place  the  needles 
on  a  wire-netting  supported  in  the  oil ;  for  drops  of  water  will  surely  be 
sustained  at  the  points  where  the  needles  cross  each  other,  and  where 
they  cross  the  wires,  and  at  the  points  where  the  wires  interlace. 

Uutil  we  know  of  a  better  method  of  preserving  the  needles  for  imme- 
diate use,  I  would  suggest  the  following  one:  Thread  the  needles  with 
dry  silk.  Tie  the  silk  with  one  knot  in  the  eye  of  the  needle.  Bend 
to  a  little  more  than  a  half  cylinder  an  oblong  piece  of  very  fine  brass 
wire-netting  on  its  long  axis,  and  thrust  the  points  of  the  threaded 
needles  through  the  netting  along  the  line  of  its  greatest  convexity. 
When  a  needle  has  been  passed  almost  through  the  netting  wind  its 
thread  about  the  half  cylinder  and  tie  the  ends  of  the  thread  together 
near  the  eye  of  the  needle.  When  all  the  needles  have  been  introduced, 
and  their  threads  wound  and  tied,  place  the  wire-netting  thus  armed  in 


458       HALSTED,  CIRCULAR   SUTURE  OF  INTESTINE. 


a  cylindrical  jar  filled  with  the  oil  of  juniper  berries.  Use  the  lowest 
needles  first. 

It  certainly  would  be  a  great  gain  to  the  technique  if  such  presection 
/iaZf-stitclies  could  be  devised,  that  one  complete  row  of  them  on  each 
side  of  the  portion  of  intestine  to  be  resected  would  suffice  for  the  cir- 
cular suture.  I  say  Aa//-stitches  because,  though  the  application  of  com- 
plete presection  stitches  {vide  Fig.  7)  is  easy,  it  is  rather  annoying  to 

Fig.  7. 


Plain-quilt,  presection  stitches  introduced. 

resect  under  them  and  to  arrange  them  for  tying  (vide  Experiments  11, 
14,  and  15,  Group  II.). 

I  have  tried  to  perform  circular  suture  of  the  intestine  with  presection 
Aa/f-stitches — one  complete  row  of  them  on  each  side  of  the  portion  of 
intestine  to  be  resected  (vide  Groups  III.  and  IV.) — and,  thus  far,  with 
unsatisfactory  results. 

Group  III.  One  Complete  Row  of  Buried-knot,  Presection 
Submucosa  Sutures. 

(For  buried-knot  stitches,  vide  Fig.  2,  p.  452,  and  Fig.  5,  p.  454.) 

Experiment  1. — Small,  black  dog.  Operation  February  2,  1887.  To 
make  single  circular  suture  with  one  complete  row  of  presection,  buried-knot 
stitches.  The  operation  lasted  three-quarters  of  an  hour  from  the  first  cut 
into  the  abdominal  wall  until  the  application  of  the  dressing.  Irrigation  with 
solution  of  corrosive  sublimate  of  uncertain  strength. 

February  3.  Dog  evidently  not  feeling  well. 

5th.  Found  dead.  Autopsy:  No  signs  of  inflammation  in  the  peritoneal 
cavity;  not  even  at  the  site  of  the  suture.  Positive  evidences  of  corrosive 
sublimate  irritation  (vide  Experiment  2,  Group  II.  Autopsy). 

Experiment  2.— Small  skye-terrier.  Operation  February  2,  1887.  To 
make  a  single  circular  suture  with  one  row  of  buried-knot,  presection  stitches. 
The  operation  for  circular  suture  lasted  thirty-five  minutes.  Irrigation  with 
the  same  strong  corrosive  sublimate  solution  as  in  the  preceding  case. 

February  3.  Dog  found  dead.  Autopsy :  Subperitoneal  vascular  injection 
and  hemorrhagic  extravasations.  Blood-tinged  fluid  in  the  peritoneal  cavity, 
etc.  The  circular  outure  is  firm  ;  holds  water  injected  with  sufficient  force  to 
distend  the  intestine;    Death  from  too  strong  an  irrigation  fluid. 

Experiment  3 — Rather  small  skye-terrier.  Operated  February  3,  1887. 
Same  suture  as  in  foregoing  cases.  Operation  performed  in  thirty-four 
minutes. 

February  8.  Dog  is  dying.  Killed.  Autopsy:  Purulent  peritonitis,  start- 
ing from  the  circular  suture. 


HALSTED,  CIECULAB   SUTURE    OF  INTESTINE.  459 


Experiment  4.— Small  fox-terrier.  Operation  February  4,  1887.  Same 
suture  as  in  foregoing  experiments  of  this  group.  Irrigation  with  solution  of 
corrosive  sublimate,  1 : 10,000. 

February  8.  Dog  is  dying.  Killed.  Autopsy:  Purulent  peritonitis,  starting 
from  line  of  circular  suture. 

Experiment  5. — Medium-sized,  fox-terrier  bitch.  ,  Operation  February  7, 
1887.  Same  suture  as  in  foregoing  experiments  of  this  group.  Irrigation 
with  ordinary  cold  water. 

February  21.  Dog  is  failing.  Killed.  Autopsy:  Intestines  badly  matted 
together  by  adhesions.  Circumscribed  abscess  cavity  surrounding,  almost 
completely,  the  circular  suture,  which  latter  appeared  to  be  firmly  healed. 

Experiment  6. — Medium-sized,  jet-black  bitch.  Operation  January  27, 
1887.  To  reverse  a  portion  of  the  intestine.  Double  circular  suture.  Pre- 
section  buried-knot  stitches.    Operation  lasted  one  and  three-quarters  hours. 

January  29.  Dog  died.    Autopsy:  Purulent  peritonitis. 

Experiment  7. — Medium-sized  dog.  Operation  February  4,  1887.  To 
reverse  portion  of  intestine.    Operation  the  same  as  in  Example  6. 

February  9.  A.M.,  suddenly  taken  sick,  p.m.,  died.  Autopsy:  Peritonitis. 
Abdomen  distended  with  sero-purulent  fluid. 

Group  IV.    Emmert's  Stitches. 

In  the  experiments  of  this  group  such  presection  stitches  were  applied 
as  are  represented  in  Fig.  8. 


Fig.  8. 


Eomerfs  stitches. 


The  idea  of  making  such  stitches  I  believed  to  be  original  with  me, 
until  I  ascertained  that  I  had  been  anticipated  in  the  conception  of  them 
by  Emmert,1  who,  however,  had  employed  them  only  to  sew  up  linear 
wounds  of  the  intestine,  and  not  for  the  circular  suture. 

Experiment  1. — Operation  January  20,  1887.  Single  circular  suture  by 
one  complete  row  of  Emmert's  stitches. 

January  21.  Dog,  evidently,  has  peritonitis. 

22d.  Found  dead.  Autopsy :  Suture  had  given  away.  Suppurative  peri- 
tonitis. 

Experiment  2. — Large,  pointer  dog.  Operation  February  9, 1887.  The 
same  suture  as  in  Experiment  1. 

February  11.  Dog  found  dead.  Autopsy:  Purulent  peritonitis  starting  from 
the  circular  suture. 

Experiment  3. — Small,  black-and-tan  dog.  Operation  February  11, 1S87. 
Single  circular  suture  (Emmert's  stitches)  as  in  Experiments  1  and  1 

February  12.  Dog  died.  Autopsy:  Purulent  peritonitis  starting  from  the 
circular  suture. 

l  Emmert :  Pitha  und  Billroth's  Ilandb.  d.  Chirurgie,  Abseh.  vii.  p.  809. 


460       II ALSTED,  CIRCULAR   SUTURE  OF  INTESTINE. 

I  shall  not  record  the  rest  of  my  experiments  on  circular  suture  of  the 
intestine,  because  most  of  them  seem,  now,  rather  absurd  to  me,  and 
none  of  them  admit  of  classification. 

Summary. 

1.  It  is  impossible  to  suture  the  serosa  alone,  as  advised  by  authors. 

2.  It  is  impossible  to  suture  unfailingly  the  serosa  and  muscularis 
alone,  unless  one  is  familiar  with  the  resistance  offered  to  the  point  of 
the  needle  by  the  coats  of  the  intestine.  Furthermore,  stitches  which 
include  nothing  but  these  two  coats  tear  out  easily,  and  are,  therefore, 
not  to  be  trusted. 

3.  Each  stitch  should  include  a  bit  of  the  submucosa.  A  thread  of 
this  coat  is  much  stronger  than  a  shred  of  the  entire  thickness  of  the 
serosa  and  muscularis.  It  is  not  difficult  to  familiarize  one's  self  with 
the  resistance  furnished  by  the  submucosa,  and  it  is  quite  as  easy  to  in- 
clude a  bit  of  this  coat  in  each  stitch  as  to  suture  the  serosa  and  muscu- 
laris alone. 

4.  It  is  unnecessary  in  performing  circular  suture  of  the  intestine  to 
make  more  than  one  complete  row  of  stitches  if  they  be  of  the  plain- 
quilt  variety.  Unless  all  of  the  stitches  of  the  row  are  applied  before  a 
single  one  is  tied,  it  is  impossible  to  preserve  a  straight  line  in  the  appli- 
cation of  them. 

5.  It  facilitates  the  operation  very  much  to  make  five  or  six  presection 
sutures;  for  the  eversion  of  the  mucous  membrane,  which  otherwise 
takes  place  and  makes  the  application  of  first-row,  postsection  stitches 
troublesome,  is  thus  prevented.  The  first  presection  stitches  should  be 
introduced  at  the  mesenteric  border  of  the  intestine,  and  at  a  place  as 
free  from  fat  as  possible. 

6.  The  plain-quilt  stitches  are  to  be  preferred  to  the  ordinary  Lem- 
bert's  stitches  (Knopfnahte)  because,  1,  one  row  of  them  (the  former)  is 
sufficient  for  the  circular  suture ;  2,  the  knots  of  the  first  row  of  Lem- 
bert's  stitches  prevent  the  most  accurate  apposition  of  the  opposed  peri- 
toneal surfaces ;  3,  the  plain-quilt  stitches  constrict  the  tissues  less  than 
the  Lembert's  stitches ;  and,  4,  the  former  tear  out  less  easily  than  the 
latter.  Madelung's  cartilage-plates,  which  he  employs  partly  to  prevent 
the  tearing  out  of  the  stitches,  are  unnecessary  when  a  bit  of  the  sub- 
mucosa is  taken  up  with  each  stitch. 

7.  The  vessels  of  the  excised  intestine  should  be  ligated  by  circum- 
vection  ("  Umstechung ").  It  is  not  necessary  to  exsect  a  triangular 
piece  of  mesentery ;  and  it  is  unadvisable  to  sew  together  the  edges  of 
the  rent  in  the  mesentery,  for,  in  so  doing,  one  might  include  small 
vessels  which  contribute  to  the  blood-supply  of  the  sutured  parts. 

8.  Solutions  of  corrosive  sublimate  stronger  than  1 : 20,000  should 


TAYLOR,  MALIGNANT   DEGENERATION   OF   KIDNEY.  461 


not  be  used  for  irrigation.  It  would  be  better,  perhaps,  to  employ 
weaker  solutions  (1:30,000  or  1:40,000).  The  irrigation  should  be 
attended  to  most  diligently  when  the  stitches  are  being  tied. 


PRIMARY  MALIGNANT  DEGENERATION  OF  THE  KIDNEY  IN 

INFANCY.1 

By  H.  Longstreet  Taylor,  A.M.,  M.D., 

ASSISTANT  TO  THE  CHAIR  OF  SURGERY,  AND  PHYSICIAN  IN  THE  CHILDREN'S  CLINIC, 
MEDICAL  COLLEGE  OF  OHIO,  CINCINNATI. 

Primary  malignant  degeneration  of  the  kidney  is  most  frequently 
met  with  at  the  two  extremes  of  life,  infancy  and  old  age.  It  is  to  the 
study  of  it  as  it  appears  in  the  first  period  that  attention  is  invited. 

Although  this  is  comparatively  a  rare  affection,  yet  one  hundred  and 
forty-four  cases  have  been  collected,  and  without  doubt  a  more  diligent 
search  and  better  facilities  than  are  afforded  by  the  libraries  of  this 
city  would  reveal  many  more.  As  the  disease  has  quite  a  typical 
course  and  array  of  symptoms,  it  can  best  be  described  by  the  detailed 
history  of  a  case. 

Case  L-Wm.  P.,  three  years  old,  was  first  seen  by  me  July  6,  1886. 
He  was,  at  that  time,  an  extremely  emaciated  child  with  an  anxious  ex- 
pression, not  so  much  indicating  pain,  as  it  did  the  presence  of  some 
serious  constitutional  condition  ;  it  was,  in  short,  a  very  decided  cachexia. 
Beneath  his  thin  pinched  face  and  flat  thorax  a  remarkably  prominent 
.abdomen  at  once  attracted  attention. 

The  parents  gave  the  following  history:  The  child  had  always  enjoyed 
good  health.  In  the  early  spring  he  seemed  to  tire  easily,  and  was  gener- 
ally seen  to  sit  quietly  by  and  not  take  much  part  in  the  play  of  the 
other  children.  This  continued  until  late  in  April,  when  he  had  fre- 
quent and  persistent  turns  of  vomiting,  which  continued  for  a  week  or 
more,  and  resisted  all  the  efforts  to  allay  them.  Early  in  May  a  hard 
swelling  was  accidentally  felt  in  the  left  side.  About  this  time  he 
began  to  loose  flesh  and  appetite  and  to  have  restless  nights,  and  since 
this  time  his  condition  had  grown  rapidly  and  steadily  worse.  His  ap- 
petite was  gone,  his  extremities  were  reduced  to  mere  skin  and  bones, 
and  the  tumor  in  the  abdomen  was  growing  rapidly.  This  increase  in 
.size  had  not  been  accompanied  by  any  symptoms  except  an  occasional 
turn  of  diarrhoea  or  a  recurrence  of  the  vomiting. 

The  family  history  was  good,  except  that  the  paternal  grandfather 

1  Read  before  the  Cincinnati  Academy  of  Medicine,  18S7. 

I  desire  to  express  my  acknowledgment  to  the  following  gentlemen  for  their  valuable  assistance, 
in  furnishing  notes  of  cases,  etc.,  in  the  preparation  of  this  paper,  Profs.  Franz  Kiinig,  S.  W.  Gross, 
•  Charles  West,  John  Croft,  Itoswell  Park,  Mr.  It.  J.  Godlee,  Mr.  II.  P.  Symonds,  and  Dr.  A  SetttMt. 
Also  to  Drs.  Stewart,  French,  and  Heudley  for  their  assistance  in  the  microscopical  work,  and  to  Prof. 
Forchheimer  for  the  use  of  his  valuable  library. 


462     TAYLOR,   MALIGNANT  DEGENERATION   OF  KIDNEY. 


had  had  a  cancer  successfully  removed  from  his  lip  in  Freiburg,  a  few 
months  previously. 

Physical  examination  revealed  a  smooth  round  tumor,  occupying  the 
left  half  of  the  abdomen,  and  giving  an  indistinct  feeling  of  fluctuation. 
The  subcutaneous  abdominal  veins  were  greatly  enlarged,  as  were  those 
of  the  right  thigh.  Dulness  on  percussion  extended  from  the  ribs  to  the 
crest  of  the  ilium,  and  from  the  median  line  of  the  back  to  the  um- 
bilicus. The  greatest  measurement  around  the  abdomen  was  twenty- 
four  inches.  The  patient  was  put  under  the  influence  of  an  anaesthetic, 
when  a  loop  of  intestine,  which  seemed  to  be  the  colon,  was  discerned 
passing  across  the  surface  of  the  tumor  from  the  left  side  above  and 
without  downward  and  inward  toward  the  right  half  of  the  pelvis. 
Three  or  four  deep  punctures  were  made  into  the  tumor  with  a  large 
needle,  through  which  several  ounces  of  a  thick  fluid,  of  a  dark  red 
color,  were  aspirated.  But  it  was  not  possible  to  reduce  the  size  of  the 
tumor  by  aspiratiou.  This  fluid  did  not  coagulate,  and  the  microscope 
revealed  the  presence  in  it  of  a  large  number  of  red  and  white  corpuscles, 
large  proliferating  cells,  and  a  few  poorly  defined  crystals. 

The  diagnosis  was  now  made  of  a  malignant  degeneration  of  the  kid- 
ney, probably  sarcomatous  in  nature.  This  was  based  upon  the  follow- 
ing grounds :  The  tumor  had  begun  above  and  had  not  come  up  from 
the  pelvis,  consequently  it  Was  in  some  organ  either  in  or  behind  the  ab- 
dominal cavity.  An  echinococcus  cyst  was  excluded  by  the  results  of 
the  aspiration,  as  was  also  a  congenital  cyst  of  the  peritoneum.  A  leu- 
cocythsemic  spleen  was  excluded,  as  there  was  not  a  general  enlargement 
of  the  lymphatic  glands,  only  a  few  small  ones  could  be  detected  in  the 
axilla  of  the  right  side.  There  was  no  history  of  chronic  malarial  poi- 
soning, nor  of  any  long-continued  suppuration,  which  might  have  pro- 
duced on  the  one  hand,  an  ague  cake,  and  on  the  other  an  amyloid 
spleen.  Malignant  degeneration  of  the  spleen  in  infancy  is  practically 
unknown,  as  is  also  that  of  the  pancreas.  But  the  fact  that  a  loop  of 
intestine  was  found  fixed  upon  the  anterior  surface  of  the  tumor  in- 
dicated very  clearly  that  it  was  a  retroperitoneal  growth,  and,  therefore, 
either  from  the  retroperitoneal  glands  or  kidney.  As  the  glands  do  not, 
when  enlarged,  cause  a  uniform  tumor  with  a  smooth  surface,  the  kidney 
was  clearly  indicated  as  the  seat  of  the  affection. 

Pyonephrosis  does  not  give  rise  to  tumors  of  this  size,  especially  in  in- 
fancy, and  the  characteristic  changes  in  the  urine  were  absent.  Tuber- 
cular degeneration  of  the  kidney  was  excluded  for  much  the  same 
reason,  and  because  no  other  symptoms  of  tuberculosis  existed.  The 
results  of  the  aspiration  excluded  hydronephrosis,  and  also  a  fibrocystic 
degeneration  of  the  kidney.  Cystic  degeneration  of  the  kidney  is  not 
uncommon  in  utero,  which  condition  is  usually  bilateral,  but  after  this 
period  it  is  seldom  met  with  until  middle  life. 

The  diagnosis  was  therefore  made  of  a  malignant  degeneration  of  the 
kidney  with  fatal  prognosis.  The  child  had  no  fever  after  the  aspira- 
tion and  no  pain,  except  such  as  was  due  to  the  presence  of  the  tumor. 
Three  days  later,  however,  the  waist  measure  had  increased  to  twenty- 
five  inches. 

Careful  and  repeated  examinations  of  the  urine  revealed  nothing  ab- 
normal, except  that  the  quantity  was  small  and  the  specific  gravity 
correspondingly  high. 

July  22d  the  abdomen  measured  twenty-six  inches  in  circumference.. 


TAYLOR,  MALIGNANT   DEGENERATION   OF    KIDNEY.  463 


On  the  26th  the  breathing,  which  had  always  been  shallow  and  rather 
rapid,  was  observed  to  be  much  accelerated  and  very  difficult.  The 
patient  had  been  coughing  a  great  deal  during  the  night  and  the  lungs 
were  found  to  contain  numerous  coarse  mucous  rales,  especially  in  the 
lower  lobes.  It  is  a  question  whether  or  not  the,  metastatic  growths, 
found  upon  the  post-mortem  table,  in  the  pleural  cavities  could  have 
caused  this  catarrh.  At  the  time  it  was  supposed  to  be  due  to  oedema, 
as  there  was  more  or  less  pleural  oedema  present. 

For  some  time  he  was  propped  up  in  his  baby  carriage  with  pillows, 
where  he  remained  day  and  night  except  when  occasionally  placed  in 
an  easy  chair.  At  all  times,  however,  he  retained  the  upright  position 
on  account  of  the  dyspnoea,  which  became  very  distressing  if  he  relin- 
quished it  for  a  moment.  He  drank  milk  with  apparent  relish,  but  took 
little  or  no  solid  food. 

All  this  time  he  had  had  no  fever,  but  on  the  3d  of  August  his  tem- 
perature rose  to  100°  P.,  in  the  afternoon.  This  slight  fever  disappeared 
again  in  a  few  days.  The  oedema  had  grown  so  marked  that  his  eyes 
were  partially  closed  by  it.  His  respirations,  however,  numbered  only 
thirty-two  to  the  minute  and  there  were  not  so  many  rales  in  the  lungs. 

The  orthopncea  and  dyspnoea  remained  unchanged.  The  size  of  the 
tumor  gradually  increased  until  the  abdomen  measured  twenty-nine 
inches  in  circumference.  Large  tortuous  veins  passed  up  over  Poupart's 
ligaments  and  spread  out  over  the  abdominal  wall.  The  eyes  were 
almost  closed  by  the  puffy  lids,  and  the  legs  wrere  swollen  and  tense  as 
high  as  the  knees.  Bandages  had  been  worn  upon  the  legs  for  some 
time  to  sustain  the  skin.  The  tumor  gradually  enlarged  until  it  had 
passed  beyond  the  median  line.  Its  edge  was  distinct,  although  rounded 
off.  The  colon  could  often  be  seen  distended  with  gas,  forming  a  marked 
prominence  across  the  tumor.  Its  position  never  changed,  and  when  it 
was  not  distended  ii  could  always  be  felt  as  a  prominent  band  passing 
over  the  front  of  the  tumor.  During  the  last  weeks  diarrhoea  had  been 
almost  constant.  His  strength  failed  until  he  was  scarcely  able  to  lift  a 
small  cup  of  milk  to  his  lips.  His  entire  attention  was  concentrated 
upon  securing  a  sufficient  supply  of  air,  as  the  upward  pressure  from  the 
abdominal  cavity  had  apparently  left  but  little  available  lung  space. 
His  death,  on  September  8th,  was  easy  and  due  to  exhaustion. 

The  post-mortem  examination  was  made,  with  the  assistance  of  Dr. 
K.  W.  Stewart,  three  hours  after  death. 

Thorax.  Right  lung :  Free  from  adhesions,  tissue  normal  at  the  base ; 
resting  upon  the  diaphragm  and  adherent  to  the  visceral  pleura  were 
two  kidney-shaped  bodies  about  the  size  of  pigeon's  eggs,  of  brain-like 
consistency  and  a  uniform  brownish  color  upon  section.  Left  lung:  Free 
from  adhesions.  Contained  a  small,  hard,  yellowish  nodule  in  the  lower 
lobe,  slightly  emphysematous  at  margins.  At  the  base  of  the  lung  there 
were  growths  similar  to  those  on  the  right  side,  but  adherent  to  the 
parietal  layer  of  the  pleura.    Heart  empty  and  normal. 

Abdomen.  Contained  about  three  ounces  of  yellowish  clear  fluid.  A 
tumor  extending  from  one  and  a  hall' inches  below  the  xiphoid  cartilage 
to  the  pubes  appeared  in  the  incision,  and  was  crossed  by  the  descending 
colon,  the  latter  running  diagonally  in  the  direction  from  the  left  nipple 
to  the  right  iliac  fossa,  in  which  fossa  the  sigmoid  flexure  rested,  passing 
thence  across  the  base  of  the  tumor  to  the  rectum.  The  meso-colon  sepa- 
rated in  both  directions  over  the  tumor  and  was  adherent  to  it,  but  could 
be  stripped  off ;  the  transverse  meso-colon  was  also  adherent  in  the  upper 


464     TAYLOR,   MALIGNANT  DEGENERATION  OF  KIDNEY. 


portion  to  a  slight  extent.  Upon  the  right  side  the  hand  could  be  passed 
around  the  tumor  to  the  vertebral  column  without  encountering  resist- 
ance ;  upon  the  left  side  a  few  soft  adhesions  existed  between  the  surface 
of  the  tumor  and  the  abdominal  wall,  but  these  were  easily  broken 
through,  thus  allowing  the  hand  to  pass  from  the  left  iliac  fossa  to  the 
margin  cf  the  ribs,  but  not  external  to  the  mammary  line,  this  obstruc- 
tion being  caused  by  the  attachment  of  the  reflected  peritoneum  upon 
the  abdominal  wall.  When  this  reflection  of  the  peritoneum  had  been 
incised  the  hand  passed  quite  readily  through  a  loose  connective  tissue 
around  the  tumor  to  the  vertebral  column. 

Upon  the  left  side  of  the  tumor,  in  the  line  between  the  nipple  and 
iliac  spine,  were  two  hemorrhagic  spots  about  the  size  of  a  quarter  of  a 
dollar.  Over  the  entire  surface  of  the  tumor,  wherever  the  peritoneal 
covering  was  removed,  were  numerous  openings  through  which  a  cheesy 
material  exuded.  The  tumor  was  larger  than  the  largest  head,  and  had 
the  appearance  of  an  immense  brain  with  the  dura  mater  covering  it. 
Numerous  large  bloodvessels  ran  in  all  directions  over  the  surface. 

The  tumor  was  tightly  adherent  to  the  pancreas  on  its  under  surface, 
and  also  to  the  diaphragm  at  its  lower  posterior  segment  upon  the  left 
side.  In  separating  this  last  adhesion  the  diaphragm  was  broken  through, 
giving  exit  to  some  serous  fluid  from  the  pleural  cavity. 

The  tumor  was  easily  shelled  out  from  its  peritoneal  covering,  but  in 
doing  so,  a  cyst  situated  in  the  upper  part  was  ruptured  and  discharged 
a  heavy,  thick,  caseous  material.  This  cyst  was  about  the  size  of  a  large 
goose  egg  and  had  no  connection  with  other  parts  of  the  tumor. 

Where  the  renal  artery  entered  the  tumor  a  thick  pedicle  was  divided. 
The  large  veins  from  the  surface  all  came  together  here.  The  renal 
artery  was  not  larger  than  that  of  the  right  side.  The  tumor  was  evi- 
dently a  degenerated  left  kidney  of  which  no  trace  could  be  found. 

The  left  ureter  entered  the  posterior  inferior  portion  of  the  tumor. 

The  small  intestine  and  stomach  were  normal. 

The  right  kidney  was  slightly  hypersemic. 

The  spleen  was  free  from  adhesions,  although  it  had  been  pushed  high 
up  in  the  vault  of  the  diaphragm  by  the  tumor. 

The  pancreas  was  closely  adherent  to  the  upper  surface  of  the  tumor. 

The  liver  was  hypersemic.  It  had  been  pushed  downward  and  toward 
the  right  side,  but  was  not  adherent  to  the  tumor. 

The  tumor  weighed  3065  grammes,  about  7  pounds.  On  section  it 
presented  the  appearance  of  an  enormously  expanded  kidney.  The  cor- 
tical portion,  about  an  inch  and  a  half  thick,  was  honeycombed  with 
blind  pouches  extending  into  it  from  a  large  central  cavity.  Some  of 
these  pouches  Avere  large  enough  to  allow  the  insertion  of  a  finger,  others 
were  much  smaller.  All  of  these  central  cavities  were  filled  by  a  semi- 
solid, exceedingly  offensive  mass  containing  a  large  proportion  of  blood. 

Drs.  James  French  and  R.  W.  Stewart  kindly  made  microscopical  ex- 
aminations of  the  tumor,  and  reported  that  it  was  a  round-celled  sarcoma, 
containing  remnants  of  the  kidney  structure.  The  metastatic  growths 
from  the  thorax  were  typical  examples  of  the  round-celled  sarcoma. 

Dr.  Stewart  reported  an  apparent  alveolar  structure,  which  was  due 
to  large  tubes  or  vessels  filled  with  round  cells. 

The  case  just  described  is  in  many  respects  a  typical  one.  The  age  of 
the  patient,  which  was  three  years,  corresponds  exactly  with  the  average 
age  as  given  in  one  hundred  and  thirty  cases. 


TAYLOK,   MALIGNANT   DEGENERATION   OF   KIDNEY.  465 


Of  these,  twenty  per  cent,  were  under  a  year,  twenty  four  per  cent, 
between  one  and  two  years,  seventeen  per  cent,  between  two  and  three 
years,  twenty-one  per  cent,  between  three  and  four  years :  sixty  per 
cent,  of  the  cases  thus  occurring  in  the  first  three  years  of  life,  and  over 
eighty  per  cent,  in  the  first  four  years. 

As  is  usually  the  case,  the  beginning  of  the  disease  was  very  insidious, 
and  no  exact  time  can  be  given.  This  is  partly  due,  no  doubt,  to  the 
fact  that  the  inaccessible  position  of  the  kidney  shields  it  from  observa- 
tion. I  am  strongly  inclined  to  the  belief  that  these  tumors  are  always 
congenital,  and  that  their  growth  may  either  begin  during  the  intra- 
uterine period,  or  that  they  may  remain  dormant  until,  from  some  cause 
or  other,  they  are  stimulated  into  active  development.  That  they  may 
grow  even  before  the  birth  of  the  child  is  shown  by  the  cases  reported  by 
Jacobi,  Paul,  and  Osier,  in  seven  and  eight  month  foetuses.  One  case  is 
recorded  as  having  been  eight  years  in  developing  in  an  eight  year  old 
child.  In  quite  a  number  of  cases  the  rapid  growth  dates  from  a  trauma, 
to  which  the  degeneration  has  been  attributed  by  some  authors.  In 
these  cases  the  dormant  heterogeneous  tissue  has  probably  been  stimu- 
lated by  the  trauma  into  activity.  This  theory  of  their  congenital  origin 
is  supported  by  the  tender  age  of  the  vast  majority  of  patients,  and  by 
the  observations  and  deductions  of  Cohnheim  and  Grawitz.  Cohnheim's 
explanation  of  the  presence  of  striped  muscular  fibres  in  a  small  per- 
centage of  these  cases  is,  that  owing  to  the  close  relationship  in  position 
of  the  first  rudiments  of  the  uro-genital  organs  to  the  proto-vertebrse,  by 
faulty  segmentation  of  the  latter  some  of  the  germinal  muscle-cells  may 
become  incorporated  with  the  cells  constituting  the  first  rudiments  of  the 
kidneys,  and  that  these  germinal  muscle-cells  afterward  develop  into  the 
pathological  new  growth.  Grawitz  has  observed  small  collections  of  the 
tissue  of  the  renal  capsule  incorporated  in  the  kidney.  He  accounts  for 
its  presence  in  the  same  way  that  Cohnheim  accounts  for  the  muscular 
fibres — i.  e.,  by  a  fault  in  the  development.  These  small  islands  of  tissue 
may  remain  in  their  abnormal  position  for  years  and  apparently  never 
develop,  or  after  an  indefinite  period  they  may  begin  to  grow,  giving  rise 
to  cancerous  tumors.  Grawitz  found  small  collections  of  cells  resem- 
bling the  tissue  of  the  suprarenal  capsule  in  the  kidneys  of  adults  where 
they  had  apparently  remained  dormant  during  the  entire  life  of  the  in- 
dividual, giving  rise  to  no  symptoms  and  no  local  disturbance.  The 
duration  of  these  cases,  dating  from  the  first  symptoms,  whether  that  be 
a  tumor,  hematuria,  persistent  vomiting  or  pain,  is  misleading,  for,  as 
stated  above,  they  are  all  probably  of  congenital  origin.  The  average 
duration  of  the  sixty-two  cases  in  which  it  is  mentioned,  is  seven  ami  a 
quarter  months.  The  shortest  time  is  six  days  and  the  longest  eighl 
years.  Of  the  symptoms  mentioned  the  tumor  is  more  apt  to  be  the  first 
observed  than  any  of  the  others.    Seibert,  who  analyzed  fifty  cases  in 

NO.  CLXXXVIII. — OCTOBER,  1887.  30 


466     TAYLOK,   MALIGNANT   DEGENERATION  OF  KIDNEY. 


his  excellent  article  on  hsematuria  in  this  disease,  found  that  in  thirty- 
six  of  these  the  tumor  was  the  first  symptom. 

In  the  case  just  described  the  patient  was  a  male,  and  the  tumor  was 
on  the  left  side,  while  in  the  next  case  the  patient,  a  female,  had  the 
tumor  on  the  right  side.  These  two  cases  are  typical  ones  in  regard  to 
sex  and  position  of  the  tumor,  as  in  all  the  cases  neither  sex  has  any 
advantage  over  the  other  in  immunity  from  the  disease,  nor  can  it  be 
said  that  it  is  more  likely  to  be  found  on  one  side  of  the  body  than  the 
other. 

Hematuria  occurs  in  about  fifty  per  cent,  of  all  cases,  but  in  a  great 
many  of  these  it  comes  on  late  in  the  course  of  the  disease  or  after  the 
tumor  has  been  discovered.  It  is  a  symptom  of  the  greatest  importance 
in  that  small  percentage  of  cases  in  which  it  is  the  first  danger  signal 
and  by  means  of  which  an  early  diagnosis  may  sometimes  be  made.  It 
was  present  in  fifty  per  cent,  of  the  cases  in  which  the  presence  or  ab- 
sence of  the  hsematuria  was  referred  to  in  the  reports.  In  those  under 
one  year  of  age  hsematuria  was  present  in  thirty-seven  and  a  half  per 
cent.,  while  in  those  between  one  and  five  years  it  was  observed  in  fifty- 
six  per  cent.  If  we  take  the  total  number  of  cases  under  one  year  and 
suppose  that  hsematuria  was  absent  in  all  cases  in  which  no  record  is 
found,  then  it  was  present  in  but  thirteen  per  cent,  of  the  cases,  while 
in  those  between  two  and  five  years,  computed  in  the  same  manner,  it 
was  present  in  forty-four  per  cent.  In  either  case  the  increase  is  very 
marked  between  the  first  year  of  life  and  the  succeeding  ones.  In  neither 
of  the  cases  reported  in  this  paper  was  it  present  at  any  time.  Hema- 
turia depending  upon  this  condition  is  usually  profuse  in  quantity. 
Rohrer  describes  three  varieties  of  hsematuria  from  cancerous  kidneys, 
but  his  description  is  based,  for  the  most  part,  upon  observations  of 
adults.  The  hemorrhage  is  either  acute,  accompanied  by  grave  general 
symptoms  if  profuse  in  quantity,  or  is  much  less  in  quantity  and  takes 
place  without  causing  any  symptoms,  or,  lastly,  the  amount  of  blood  lost 
is  so  small  that  it  can  only  be  detected  by  the  microscope.  It  may  recur 
frequently  or  may  be  observed  but  a  few  times  in  the  entire  course  of 
the  disease.  Seibert  reports  a  case  in  which  it  was  the  cause  of  death. 
In  this  case  the  hemorrhages  had  been  excessive  in  quantity  and  very 
numerous.  Seibert's  classification  of  hsematuria  and  its  significance  is 
as  follows : 

I.  Hsematuria  occuring  in  apparently  healthy  children. 
a.  Without  pain  previous  to  the  occurrence. 
^Preceded  by  pain. 

The  hsematuria  of  nephrolithiasis  must  be  excluded  by  chemical  and 
microscopical  examination  and  by  the  amount  of  hemorrhage.  A  very 
important  factor  is  that  this  latter  hemorrhage  is  always  preceded  and 
accompanied  by  pain,  while  if  dependent  upon  malignant  degeneration 


TAYLOE,  MALIGNANT   DEGENERATION    OF   KIDNEY.  467 


the  pain  always  ceases  when  the  flow  begins.  That  is  supposed  to  be 
due  to  the  fact  that  the  blood  retained  in  the  pelvis  by  a  coagulum  in 
the  ureter  causes  pressure-pain,  which  is  relieved  when  the  pressure 
becomes  great  enough  to  force  the  blood  past  the  obstruction. 

Hemorrhage  from  a  tubercular  kidney  must  also  be  excluded,  but 
this  is  seldom  present  in  children,  and  very  rarely  unless  general  tuber- 
culosis exists. 

II.  Hematuria  occurring  in  children  in  poor  health  without  any 
apparent  cause  for  the  general  condition. 

This  variety  is  rare  because  the  tumor  can  usually  be  felt  before  it 
has  existed  long  enough  to  make  any  marked  inroad  upon  the  child's 
health. 

III.  Hematuria  occurring  in  children  during  or  soon  after  an  attack 
of  any  of  the  acute  infectious  diseases. 

This  variety  may  occur  as  the  result  of  an  acute  inflammation  in  a 
healthy  orgau,  but  is  then  neither  so  profuse  nor  of  as  long  duration  as 
that  from  an  organ  which  is  the  seat  of  malignant  degeneration. 

IV.  Hematuria  occurring  in  the  course  of  chronic  inflammation  of 
the  kidneys. 

If  the  hemorrhage  takes  place  without  any  symptom  of  an  acute 
exacerbation  of  the  chronic  inflammation,  cancer  must  be  thought  of, 
if  renal  calculus  can  be  excluded. 

Upon  the  post-mortem  table  metastatic  deposits  were  found  in  the 
lung,  and  also  attached  to  the  pleura  in  the  case  just  reported.  Primary 
malignant  growths  in  the  kidney,  as  has  been  known  for  a  long  time, 
have  little  tendency  to  produce  secondary  deposits  in  other  organs.  They 
frequently  attain  great  size,  but  are  prone  to  remain  within  the  strong 
capsule  in  which  their  development  first  began.  This  is  as  true  of  these 
tumors  in  infants  as  in  adults,  and  truly  marvellous  examples  of  this 
peculiarity  can  be  seen  in  the  three  largest  tumors  on  record,  two  of 
which  weighed  thirty-one  pounds  each  and  one  twenty-seven  and  a 
quarter  pounds,  and  yet  no  secondary  deposits  were  present  in  any  of 
them.  In  fifty  per  cent,  of  the  cases  collected,  in  which  death  was  due 
to  the  disease,  no  metastatic  deposits  were  present.  This  is  a  fact  worthy 
of  the  most  careful  consideration  and  which  will  be  referred  to  again  in 
discussing  the  permissibility  of  the  removal  of  these  tumors  by  operative 
measures.  In  the  cases  in  which  secondary  deposits  were  found  their 
seat  was  most  frequently  in  the  lungs  or  the  liver,  and  with  the  next 
greatest  frequency  in  the  retroperitoneal  and  mesenteric  glands. 

These  tumors  show  comparatively  little  tendency  to  produce  secondary 
growths  and  even  a  more  marked  immunity  from  adhesions  to  the  organs 
of  the  abdominal  cavity.  This  is  probably  due  to  the  fact  that  the 
tumor  without  regard  to  its  size  or  the  degenerations  which  it  has 
undergone,  remains  within  its  capsule  behind  the  peritoneum.    As  the 


468     TAYLOR,   MALIGNANT   DEGENERATION   OF  KIDNEY. 

capsule  is  thick  there  is  little  direct  irritation  of  the  peritoneum  covering 
it,  and  hence,  not  that  very  decided  tendency  to  the  production  of  adhe- 
sive inflammation  which  characterizes  malignant  tumors  within  the 
peritoneal  cavity.  The  tumor  is  also  usually  very  easily  removed  from 
within  its  capsule,  as  is  noted  in  very  many  of  the  post-mortem  records 
and  as  was  found  in  both  of  the  cases  reported  in  this  article. 

The  presence  or  absence  of  adhesions  is  found  recorded  in  fifty-five 
cases.  In  fourteen  of  these  the  adhesions  were  to  the  colon  only.  As 
the  tumor  grows  from  directly  behind  the  colon  the  mesocolon  very  soon 
becomes  part  of  its  covering,  as  the  size  of  the  tumor  increases,  and  the 
colon  is  bound  down  and  becomes  adherent,  by  means  of  its  mesocolon, 
to  the  surface  of  the  tumor.  This  is,  however,  very  readily  loosened  by 
an  incision  external  to  the  colon  and  a  little  dissection  with  the  end  of 
the  finger.  Among  these  cases  are  the  two  largest  on  record,  in  which 
the  tumors  weighed  thirty-one  pounds  each,  and  one  of  which  had 
existed  for  eight  years.  In  one  of  Abercrombie's  cases,  in  which  the 
existence  of  the  tumor  was  known  for  three  years,  there  were  no  adhe- 
sions whatsoever.  In  ten  cases  there  were  no  adhesions  and  in  four  the 
record  is  that  they  were  very  slight.  These  three  classes  give  a  total  of 
twenty-eight  cases  or  fifty  per  cent,  of  all  those  in  which  this  condition 
is  noted.  Of  the  cases  in  which  adhesions  were  described  we  find  them 
to  the  liver  twelve  times,  to  the  colon  eleven  times,  to  the  pancreas  and 
small  intestine  each  six  times,  to  the.  stomach  and  duodenum  each  three 
times,  to  the  diaphragm,  vena  cava,  and  omentum,  each  twice,  and  to 
the  sigmoid  flexure,  caecum,  opposite  kidney,  vertebral  column,  renal 
glands,  mesentery,  spleen,  aorta,  portal  vein,  ligament  hepato-renalis, 
and  the  ribs,  in  one  case  each. 

The  dimensions  to  which  these  tumors  occasionally  attain  is  mar- 
vellous when  we  consider  the  diminutive  size  of  many  of  the  patients, 
some  of  whom  were  not  much  larger  than  their  tumors.  The  largest 
tumors  of  this  class  have  been  referred  to  above,  weighing  thirty-one 
pounds  each  ;  one  in  an  infant  of  ten  months  weighed  ten  pounds.  The 
smallest  weighed  but  little  more  than  the  normal  organ,  and  between  the 
two  extremes  all  gradations  are  present.  The  average  of  the  seventy 
cases  in  which  the  weight  is  given,  is  about  seven  pounds.  The  sarco- 
matous kidney  of  infancy  is,  on  the  average,  larger  than  that  of  adult 
life.  The  entire  kidney  is  sometimes  degenerated  and  nothing  of  its 
normal  structure  remains  to  identify  it.  In  other  cases  the  growth 
would  seem  to  have  started  in  the  pelvis  of  the  kidney,  or  in  the  glands 
found  near  the  hilus,  as  in  these  cases  the  kidney  tissue  can  be  dis- 
covered lying  on  the  surface  of  the  tumor,  which  has  apparently  pressed 
it  in  front  or  to  one  side  of  it  as  it  grew.  The  boy's  case  belongs  to  the 
first  class,  while  the  case  about  to  be  reported  is  a  typical  example  of  the 
second.    In  this  case  the  kidney  formed  a  slight  prominence  upon  one 


TAYLOR,   MALIGNANT   DEGENERATION   OF   KIDNEY.  469 

side  of  the  solid  round  tumor.  The  tumors  frequently  have  cysts  in  the 
interior,  usually  containing  blood  and  broken-down  tissue,  although 
occasionally  a  clear,  viscid,  tenacious  fluid  is  found. 

The  presence  of  these  hemorrhagic  cysts  explains  why  the  diagnosis 
of  fungus  hsematodes  and  encephaloid  is  so  frequently  found,  especially 
in  cases  reported  years  ago,  when  macroscopical  diagnoses  were  more 
frequent  than  they  are  now,  since  the  more  exact  anatomical  pathological 
classification  of  to-day  requires  that  a  careful  microscopical  examination 
shall  sustain  the  clinical  and  macroscopical  diagnosis.  For  the  same 
reason  cancer  and  carcinoma  are  found  in  the  older  reports  in  a  majority 
of  the  cases,  while  in  the  more  recent  ones  some  of  the  sarcoma  group 
take  their  place.  Smith,  in  his  article  on  primary  sarcoma  of  the 
kidney  in  The  American  Journal  of  the  Medical  Sciences  for  1886,  says, 
that,  although  scirrhus  is  often  spoken  of,  it  is  rare  as  a  renal  growth. 
If  this  is  true  in  general,  it  must  be  particularly  so  in  the  case  of  infants, 
for  carcinoma  is  rare  in  infancy  aud  childhood,  and  the  kidney  forms 
no  exception  to  this  rule.  Let  us'  examine  the  cases  to  see  if  this  con- 
clusion is  supported  by  them  ;  remembering  that  some  of  them  date  as 
far  back  as  the  fourth  decade  of  this  century,  about  the  time  that  atten- 
tion was  first  called  to  the  occurrence  of  primary  malignant  degenera- 
tion of  the  kidney.  We  find  a  diagnosis  given  in  120  cases.  In  23  of 
these  the  diagnosis  is  sarcoma,  in  15  rhabdomyoma,  in  14  round-celled 
sarcoma,  in  5  spindle-celled  sarcoma,  in  5  medullary  sarcoma,  in  4  adeno 
sarcoma,  in  3  a  combination  of  spindle-  and  round-celled  sarcoma,  in  2 
myxo-sarcoma,  and  in  1  sarcoma-carcinomatosus ;  giving  a  total  in  the 
sarcoma  group  of  76  cases,  or  61  per  cent,  of  all.  In  the  carcinoma 
group  there  are,  4  carcinoma,  10  medullary  carcinoma,  and  1  carcinoma 
hsematodes  ;  a  total  of  15  cases,  not  quite  13  per  cent,  of  all.  In  a  third 
group  of  cases  in  which  the  diagnosis  may  be  regarded  as  indefinite, 
there  are  17  cases  designated  as  encephaloid,  15  malignant  and  cancerous, 
and  3  fungus  hsematodes ;  a  total  of  35  cases.  Some  of  these  cases 
might  be  referred  to  the  sarcomata  and  some  to  carcinomata,  but  that 
is  impossible  unless  they  could  be  reexamined  by  a  reliable  pathologist, 
as  was  done  by  Eve,  who  examined  a  so-called  medullary  tumor  from  the 
kidney  of  an  infant,  which  had  been  deposited  in  the  museum  of  the  Royal 
College  of  Surgeons,  London,  in  Hunter's  time,  and  discovered  that  it 
belonged  to  that  rare  group  of  tumors  which  have  been  variously  desig- 
nated as  rhabdomyosarcoma  or  as  myosarcoma  striocellulare.  More 
than  half  of  these  cases  are,  therefore,  sarcomatous  in  character,  and 
but  an  eighth  of  them  carcinomatous.  But  a  large  proportion  of  these 
cases  have  been  diagnosed  upon  evidently  insufficient  evidence  as  to  their 
true  nature  and  even  before  pathologists  had  actually  defined  the  char- 
acteristics of  the  malignant  growths  as  they  are  understood  to-day.  In 
latter  years  the  carcinomatous  kidneys  of  infants  have  been  seldom  re- 


470     TAYLOE,  MALIGNANT  DEGENERATION   OF  KIDNEY. 

ported,  and  the  proportionate  number  of  sarcomatous  tumors  has  greatly 
increased.  But  carcinoma  does  occur,  and  one  case  in  point  was  reported 
by  Dr.  Rowe,  of  Cincinnati,  in  which  the  diagnosis  was  made  by  two 
accurate  and  reliable  pathologists,  Drs.  Kebler  and  Mackenzie. 

Twenty  per  cent,  of  the  sarcomatous  tumors  have  been  found  upon 
careful  examination  to  contain  a  tissue  entirely  foreign  to  the  kidney, 
namely,  striped  muscular  fibres.  As  these  tumors  are  for  the  most  part 
spindle-  and  round-celled  sarcomata  containing  striped  muscular  fibres 
and  oftentimes  inorganic  muscular  tissue,  it  is  probable  that  a  careful 
search  would  result  in  increasing  the  number  of  the  rhabdomyosarco- 
mata.  The  presence  of  the  unstriped  muscular  tissue  is  not  difficult  to 
account  for,  as  it  normally  exists  in  the  kidney,  and  has  been  seen  there 
by  both  Henle  and  Eberth,  but  it  remained  for  Jardet,  of  Vichy,  to  de- 
scribe its  distribution.  He  found  a  system  of  muscular  fibres  springing 
from  the  pelvis  and  running  parallel  to  the  larger  arteries  and  veins  in 
the  peri  vascular  areolo-fibrous  sheath  of  the  vessels,  but  never  constituting 
a  complete  sheath  to  any  vessel  and  not  extending  far  amongst  the  renal 
tubuli.  This  muscular  tissue  becomes  hypertrophied  in  lithiasis,  hydro- 
nephrosis, and  all  chronic  inflammations.  But  while  the  inorganic 
muscular  tissue  is  thus  physiologically  present,  the  striped  muscular 
fibres  are  entirely  heterogeneous.  The  most  generally  accepted  explana- 
tion of  its  presence  is  Cohnheim's,  which  was  given  above.  Paul  de- 
scribes an  apparent  development  of  striated  fibres  from  the  sarcomatous 
elements  themselves,  in  the  case  of  a  seven  months'  foetus  examined  by 
him.  Birch-Hirschfeld  speaks  of  the  same  thing.  Such  a  development 
of  spindle  cells  agrees  with  the  observations  of  Zenker  upon  the  regen- 
eration of  muscle  in  wounds,  who  described  it  as  taking  place  from  the 
spindle  cells  of  the  interstitial  connective  tissue.  Waldeyer  agrees  with 
Zenker  upon  this  point. 

Case  II.  was  under  the  care  of  Dr.  R.  W.  Stewart.  The  child,  a 
little  girl  of  German  parentage,  one  year  and  eight  months  old,  was  large 
and  Avell  developed  for  her  age.  She  had  always  seemed  well  and  was 
unusually  active.  The  marked  prominence  of  the  abdomen  first  attracted 
the  mother's  attention  in  April,  1886,  and  caused  her  to  seek  medical 
advice.  Dr.  Stewart  saw  her  first  early  in  July.  A  few  days  later  a 
thorough  examination  of  the  case  was  made  under  an  anaesthetic.  The 
tumor  was  found  on  the  right  side  and  was  firmly  fixed  in  its  position  in 
the  lumbar  region.  The  fingers  could  be  inserted  between  the  upper 
edge  of  the  tumor  and  the  liver,  and  also  between  its  lower  border  and 
the  crest  of  the  ileum.  The  tumor  was  of  a  regular  ovoid  shape  with  a 
smooth  surface.  The  dulness  was  continuous  upon  both  gentle  and  deep 
percussion  from  the  tumor  around  to  the  median  line  of  the  back. 
Several  punctures  with  the  needle  of  the  aspirator  secured  but  a  few 
drops  of  a  thick,  gelatinous,  colorless  fluid.  There  was,  however,  no 
sensation  of  deep  fluctuation  upon  palpation.  A  fold  of  intestine, 
which  was  at  the  time  regarded  as  the  colon,  was  situated  betAveen  the 


TAYLOR,  MALIGNANT   DEGENERATION   OF   KIDNEY.  471 

tumor  and  the  anterior  abdominal  wall.  The  diagnosis  was  a  degenera- 
tion of  the  kidney,  and  the  prognosis,  therefore,  necessarily  fatal  unless 
the  tumor  could  be  removed,  to  which  the  parents  would  not  consent. 
Hematuria  was  not  present  at  any  time.  An  examination  of  the  urine 
showed  it  to  be  acid,  of  a  specific  gavity  of  1.020,  and  containing 
neither  albumen  nor  sugar. 

The  growth  of  the  tumor  was  very  rapid,  and  in  three  months  time  it 
had  increased  so  greatly  that  it  began  to  interfere  materially  with 
respiration  and  sleep.  The  parents  now  saw  that  the  child's  condition 
was  serious  and  wanted  an  operation  performed.  At  this  time  the  groove 
between  the  liver  and  tumor  had  about  disappeared ;  it  had  encroached 
upon  the  abdomen  as  far  as  the  median  line  and  extended  down  to  the 
crest  of  the  ileum.  Every  other  organ  in  the  body  seemed  to  be  per- 
fectly healthy,  and  the  tumor  was  simply  beginning  to  interfere  mechani- 
cally with  the  digestive  and  respirator}7  systems.  Therefore,  as  a  last 
resort,  it  was  decided  to  operate,  although  the  opinion  of  all  who  exam- 
ined the  case  was  that  the  chances  had  become  decidedly  against  the 
child,  and  that  three  valuable  months  had  been  lost  in  waiting.  Every 
preparation  was  made  that  could  in  any  way  have  a  favorable  influence 
on  the  result. 

On  the  afternoon  of  October  9th  I  removed  the  tumor  through  the 
anterior  abdominal  wall,  being  assisted  in  the  operation  by  Drs.  Stewart, 
Ransohoff,  Christopher,  Wilder,  and  Hendley.  Langenbeck's  incision 
was  made  because  the  tumor  was  too  large  and  solid  to  have  been  ex- 
tracted through  any  lumbar  incision  and  because  the  abdominal  incision 
was  regarded  as  the  safer,  allowing,  as  it  would,  a  thorough  exploration 
of  the  relations  of  the  tumor,  and  showing  at  once  the  existence  of  any 
dangerous  or  extensive  adhesions.  The  incision  was  made  of  moderate 
length,  but  was  immediately  lengthened  from  the  margin  of  the  ribs 
almost  to  the  crest  of  the  ilium.  The  tumor  presented,  crossed  from 
below  upward  by  the  ascending  colon.  No  adhesions  existed,  and  so  the 
peritoneal  covering  of  the  tumor  was  incised  and  torn  through  external 
to  the  large  intestine.  As  rapidly  as  possible  the  peritoneal  covering, 
together  with  the  mesocolon  and  colon,  was  dissected  loose  with  the  finger 
from  the  tumor.  Although  not  very  difficult  to  accomplish,  it  was  rather 
a  tedious  dissection.  Upon  the  lower  segment  of  the  tumor  several  large 
veins  were  ligated  and  divided  in  order  to  extend  the  incision  in  the 
peritoneum.  Then  the  lateral  attachment  to  the  peritoneum  and  the 
loose  ones,  behind  the  line  of  reflection  of  the  peritoneum  from  the  tumor 
to  the  abdominal  wall,  and  between  this  line  and  the  vertebral  column, 
were  torn  and  dissected  loose.  The  pedicle  could  now  be  readily  reached. 
The  tumor  was  drawn  out  through  the  incision,  the  pedicle  clamped, 
ligated,  and  cut  off. 

There  was  no  oozing  whatsoever  from  the  large  surface  from  which 
the  tumor  had  been  removed,  and,  after  cutting  off"  the  ligatures  and 
dropping  the  pedicle,  the  abdominal  wound  was  closed,  the  bandages 
applied,  the  child  put  to  bed  and  surrounded  with  hot  bottles.  The 
operation  had  lasted  an  hour  and  a  half,  and  the  child  had  taken  the 
anaesthetic  very  badly.  Several  times  the  ether  had  to  be  withdrawn  as 
the  respirations  became  bad  or  as  the  pulse  grew  weak,  and  twice  it  w  as 
necessary  to  give  small  hypodermatic  injections  of  whiskey  to  stimulate 
the  flagging  heart.  She  vomited  repeatedly  after  being  returned  to  bed 
and  became  entirely  conscious.     The  heart  was,  however,  weak  and 


472     TAYLOR,  MALIGNANT   DEGENERATION   OF  KIDNEY. 

rapid,  and  would  not  respond  to  any  stimulant.  Two  hours  after  the 
end  of  the  operation  the  patient  died  of  shock. 

No  post-mortem  examination  was  obtained.  The  tumor  was  round, 
with  a  slight  oval  prominence  on  one  side.  Upon  section  it  was  of  a 
uniform  grayish  white  color,  except  the  oval  prominence  on  the  side, 
which  was  evidently  kidney  tissue.  Just  between  this  kidney  and  the 
tumor  proper  were  a  few  cysts  the  size  of  marbles.  It  was  from  one  of 
these  that  the  fluid  obtained  in  the  exploratory  puncture  had  been 
drawn.    The  tumor  weighed  830  grammes,  about  2  pounds. 

Drs.  Stewart  and  Hendley  made  microscopical  examinations  of  the 
tumor,  and  found  that  it  was  a  spindle-celled  sarcoma  with  bundles  of 
connective  tissue  passing  through  it.  The  kidney  itself  was  also  sarco- 
matous, only  an  occasional  glomerulus  could  be  found,  and  the  tubules 
were  almost  entirely  obliterated. 

Eminent  authorities,  both  in  America  and  Europe,  have  expressed 
the  opinion  that  it  is  unjustifiable  to  remove  degenerated  kidneys  in 
infants,  but  these  same  authorities  for  the  most  part  advise  the  removal 
of  sarcomatous  kidneys  in  adults,  their  conclusion  being  based  upon  the 
statistics  of  the  operation.  A  critical  examination  of  the  cases  of  this 
operation  is,  therefore,  in  place  in  order  to  determine  whether  or  not 
their  verdict  should  be  final.  In  the  first  place  we  must  remember  that 
this  is  a  comparatively  young  operation,  so  young  that  Rohrer's  book, 
published  but  a  decade  ago  and  otherwise  very  complete,  does  not  even 
allude  to  the  possibility  of  operative  interference.  Also  that  but  twenty- 
five  cases  have  been  operated  upon,  and  many  of  these,  as  will  be  shown 
shortly,  were  undertaken  long  after  the  time  for  successful  interference 
had  passed. 

It  is  only  after  the  indications  for  an  operation  have  been  settled  that 
the  statistical  study  of  it  becomes  valuable,  and  that  it  may  be  con- 
demned or  admitted  to  the  ranks  of  justifiable  operations  upon  its  record 
as  established  on  a  scientific  basis.  Let  us  glance  for  a  moment  over 
some  of  the  cases  which  have  brought  the  operation  into  discredit.  In 
one  case  death  occurred  upon  the  table  from  hemorrhage.  It  was  an 
unpremeditated  nephrectomy,  as  the  diagnosis  of  a  kidney  tumor  had 
not  been  made.  The  tumor  was  very  large,  weighing  five  pounds,  and 
had  encroached  upon  the  walls  of  the  vena  cava,  hence  the  unfortunate 
accident.  Moreover,  the  tumor  had  existed  for  a  year.  In  another 
case,  of  which  the  exact  account  was  not  accessible,  the  tumor  weighed 
four  kilogrammes,  about  ten  pounds  ;  comment  is  unnecessary.  We  find 
in  the  record  of  another  case  that  the  tumor  was  very  large  and  its  entire 
removal  proved  impossible,  and  in  another  that  death  followed  the  re- 
moval of  a  very  large  tumor.  The  youngest  patient,  eleven  months  old, 
died  after  the  removal  of  a  tumor  designated  as  very  large  although  the 
exact  weight  is  not  given.  One  operator  unfortunately  included  the  vena 
cava  in  the  ligated  pedicle,  and  another  one  lost  his  little  patient,  who 


TAYLOR,   MALIGNANT   DEGENERATION   OF    KIDNEY.  473 

had  been  doing  very  well,  by  the  accidental  strangulation  of  a  loop  of 
intestine  in  the  posterior  opening  in  the  peritoneum.  These  seven  cases 
may  justly  be  excluded  from  the  consideration  as  due  to  accidents,  or  to 
be  regarded  as  operations  undertaken  simply  as  the  last  resort ;  the 
operators  and  friends  of  the  little  patients  having  accepted  the  desperate 
chances  of  an  almost  necessarily  fatal  operation,  as  being  preferable  to 
certain  death  of  a  lingering  and  exceedingly  painful  character. 

We  would  then  have  eighteen  cases  remaining.  As  the  records  of 
several  of  these  have  not  been  accessible  it  is  not  possible  to  analyze 
them  more  closely.  Of  these  eighteen  cases,  we  find  that  eight  died 
from  the  immediate  results  of  the  operation,  either  from  shock  or  septic 
complications,  and  that  ten  recovered.  Of  the  ten  that  recovered  six 
died  of  a  recurrence  of  the  disease  in  periods  extending  from  five  to 
eighteen  months  after  the  operation.  Four  were  doing  well  when  last 
heard  from.  One  of  these,  however,  is  Konig's  little  patient,  and  as  the 
operator  saw  degenerated  mesenteric  and  retro-peritoneal  glands,  he  con- 
sequently thinks  that  the  child  died  of  a  recurrence,  although  he  has 
not  heard  of  its  having  done  so. 

From  these  eighteen  cases  we  have  fifty-five  per  cent,  of  immediate 
recoveries,  but  if  the  whole  number  of  cases  be  taken  this  is  reduced  to 
forty  per  cent.  Of  those  that  recovered  six  subsequently  died  from  a 
recurrence.  The  permanency  of  the  cure  is  not  established  for  all  of 
the  remaining  cases,  as  not  a  sufficient  number  of  years  have  elapsed  to 
exclude  the  possibility  of  a  return  of  the  growth. 

For  a  condition  as  desperate  as  this,  nephrectomy  certainly  seems  to 
be  a  beneficent  measure  and  to  offer  the  only  avenue  of  escape  to  the 
victims  of  this  malady  from  certain  destruction.  Can  any  arguments 
for  or  against  the  operation  be  drawn  from  the  study  of  cases  which 
have  gone  on  to  their  fatal  termination?  Let  us  glance  back  and  see. 

The  age  of  a  majority  of  the  cases  certainly  increases  the  danger  of  the 
operation.  But  infants  undergo  many  major  operations,  and  while  there 
is  greater  liability  to  fatal  shock  than  in  adults,  yet  as  the  records  of 
nephrectomy  and  other  operations  show,  many  pass  this  danger  point  in 
safety.  One  of  the  most  remarkable  cases,  in  this  connection,  was  that 
of  Dr.  Park,  which  demonstrates  very  conclusively  that  even  the  re- 
moval of  large  tumors  from  very  young  children  is  not  necessarily  fatal. 
In  this  case  a  large  fibrocystic  tumor  of  the  right  kidney  weighing  four 
pounds  was  removed  from  a  boy  twenty-three  months  old.  He  was  in 
excellent  health  a  year  after  the  operation.  Godlee's  case  was  still 
younger,  but  the  tumor  was  not  so  large.  Both  children  recovered  with 
scarcely  an  unfavorable  symptom. 

Park's  case  is  also  a  very  interesting  one  in  this  connection,  as  its 
clinical  history  so  nearly  resembles  that  of  a  malignant  tumor,  in  the 


47-i     TAYLOR,   MALIGNANT   DEGENERATION  OF  KIDNEY. 


rapidity  of  its  growth,  its  influence  upon  the  general  health,  etc.,  that  it 
might  be  almost  impossible  to  make  a  differential  diagnosis  in  a  similar 
case ;  and  if  the  diagnosis  of  a  malignant  growth  should  be  made  the 
patient  might  be  allowed  to  die  without  an  effort  to  save  him,  although 
the  victim  of  a  benign  tumor,  only  malignant  in  its  encroachment  upon 
the  functions  of  other  organs.  This  little  patient,  to-day  enjoying  life 
and  health,  is  the  most  eloquent  argument  for  this  operation,  as  but  a 
slight  mistake  in  such  a  case  would  result  in  the  loss  of  a  life  that  might 
have  been  saved.  Who  is  so  infallible  that  he  is  never  mistaken  in  a 
diagnosis. 

The  presence  of  metastatic  deposits  in  other  organs  would,  of  course, 
render  any  operative  interference  futile.  But  it  has  been  shown  that 
they  are  not  very  liable  to  be  present,  fifty  per  cent,  of  the  cases  remain- 
ing free  from  them  even  after  the  disease  has  run  its  course. 

The  remarkable  immunity  of  even  large  tumors,  of  this  class,  from 
adhesions  to  the  abdominal  viscera  renders  their  removal  more  rapid  and 
less  dangerous  than  it  would  be  if  adhesions  were  the  rule. 

The  fact  that  in  about  one-tenth  of  all  cases  both  kidneys  have  been 
found  affected,  increases  the  dangers  of  the  operation  and  decreases  the 
chances  of  a  permanent  cure.  A  careful  examination  of  both  kidneys 
should,  therefore,  precede  every  operation.  In  this  way  the  presence  of 
a  second  tumor  might  be  discovered  and  the  operation  abandoned. 

After  a  careful  consideration  of  this  question  I  must  say  that  I  am 
decidedly  in  favor  of  the  operation,  and  think  that  if  made  when  the 
tumor  is  still  small,  its  results  in  the  percentage  of  permanent  recoveries 
will  compare  very  favorably  with  those  of  malignant  degeneration  of 
other  organs. 

The  abdominal  incision  was  made  in  all  but  three  cases.  This  was 
more  from  necessity  than  choice.  In  one  case  the  lumbar  incision  had 
to  be  lengthened  so  far  forward  that  the  peritoneal  cavity  was  opened  in 
order  to  gain  space.  The  lateral  abdominal,  or  Langenbeck's  incision, 
allows  the  posterior  opening  in  the  peritoneum  to  be  made  exterual  to 
the  colon  more  readily  than  the  median  abdominal  incision.  Konig's 
incision  is  an  oblique  one  from  above  and  external  downward  and  in- 
ward diagonally  across  the  tumor.  This  incision  would  probably  give 
more  room  and  permit  the  operator  to  ligate  the  pedicle  with  more  ease 
than  either  of  the  others.  Having  opened  the  abdomen  and  explored 
the  tumor  to  determine  the  extent  of  the  adhesions  if  any,  and,  if  pos- 
sible, the  opposite  kidney  to  exclude  a  possible  degeneration  of  it  also, 
the  next  step  is  to  open  the  posterior  parietal  layer  of  the  peritoneum 
over  the  tumor.  This  should  be  done  external  to  the  colon  and  parallel 
to  it  in  order  to  avoid  the  coeliac  arteries.  The  tumor  can  then  be  readily 
dissected  out  from  the  retroperitoneal  tissue,  as  has  been  shown  not  only 


TAYLOR,   MALIGNANT    DEGENERATION   OF   KIDNEY.  475 


in  the  operations  but  also  in  the  post-mortem  examinations  of  cases  that 
have  died  of  the  disease. 

As  in  all  nephrectomies,  the  question  of  ligating  the  ureter  or  of  simply 
allowing  it  to  take  care  of  itself,  is  still  sub  judice.  The  ligatures  on  the 
pedicle  should  be  cut  off  short  and  the  pedicle  returned  to  its  normal 
situation.  The  incision  in  the  posterior  layer  of  the  peritoneum  might 
be  carefully  closed  with  sutures  in  order  to  leave  the  cavity,  from  which 
the  tumor  has  been  removed,  behind  the  peritoneum,  and  cut  off  any 
subsequent  suppuration  here  from  the  peritoneal  cavity  by  drainage 
through  a  counter-opening  in  the  lumbar  region.  This  procedure  would 
be  particularly  indicated  when  the  dissection  has  been  difficult  and  sup- 
puration was  to  be  feared.  This  practice  has  been  followed  after  the 
removal  of  large  retroperitoneal  tumors  with  very  gratifying  success. 

The  operation,  the  statistics  of  which  I  have  given,  has  so  far  suc- 
ceeded in  lengthening  the  lives  of  ten  children,  and  of  saving  some  of 
them.  There  is  every  reason  to  hope  that  in  the  future  early  diagnosis 
-and  early  operations  will  show  a  much  larger  percentage  of  cures.  As 
in  all  other  malignant  tumors,  an  early  removal  is  necessary  to  success, 
but  even  late  operations  may  lengthen  life  and  possibly  save  it.  Konig 
says,  operate  whenever  it  is  possible.  That  is,  make  explorative  inci- 
sions, and  if  extensive  adhesions  or  visible  metastatic  growths  forbid 
further  interference,  desist  from  the  operation. 

Let  the  teachings  of  more  extended  experience  be  our  guide,  and 
until  its  light  burns  more  clearly  let  us  not  condemn  these  little  unfor- 
tunates without  making  at  least  an  effort  to  save  them. 

Note. — The  twenty-five  operations  referred  to  were  made  by  the  fol- 
lowing operators.  Konig,  three  cases;  Czerny,  Rawdon,  Godlee,  Long- 
street  Taylor,  Dandois,  Jessop,  Bardenheuer,  Pughe,  Kocher,  Croft, 
Hueter,  Meredith,  Scheven  and  Mitzel,  Oilier,  Bantock,  Reezey,  Hic- 
quet,  Schoenborn,  Little,  Barker,  Bokai,  Jr.,  and  Heath,  each  one  case. 
The  ten  cases  that  recovered  were  the  three  cases  of  Konig,  and  the 
cases  of  Godlee,  Dandois,  Jessop,  Bardenheuer,  Croft,  Hicquet,  and 
Schoenborn.  Of  these,  two  cases  of  Konig,  and  the  cases  of  Dandois  and 
Schoenborn  were  doing  well  when  last  heard  from. 

Park's  case  is  not  included,  because  it  was  not  a  malignant  degenera- 
tion of  the  kidney.    It  was  doing  well  a  year  after  the  operation. 


476 


LOVETT,  MUNEO,  TEACHEOTOMY. 


A  CONSIDERATION  OF 
THE  RESULTS  IN  327  CASES  OF  TRACHEOTOMY, 

PERFORMED  AT  THE  BOSTON  CITY  HOSPITAL  FROM  1864  TO  1887. 

By  Robert  W.  Loyett,  M.D.,  and  John  C.  Munro,  M.D., 

FORMERLY  HOUSE  SURGEONS  AT  THE  HOSPITAL. 

(Concluded  from  page  170.) 

We  herewith  present  the  tables  referred  to  in  our  article  which  ap- 
peared in  the  July  number  of  this  journal,  and  which  were  accidentally 
omitted  from  the  text. 


TABLE  I.  Curve  of  monthly  percent  of  deaths  after 
tracheotomy  at  the  Boston  City  Hospital. 
1881-85  inclusive. 


LOVETT,   MUKEO,  TRACHEOTOMY. 


MONTHS 

< 

1  JUNL  1 

3 
> 

u 

CO 

I  OCT.  I 

850 

800 

T50 

i 

\ 

700 

i 

— y 

6S0 

F- 

600_ 

* — 

i 

\ 

1 

i 

1— 

j- 

S50 

i 

f— 

\- 

4 

-V 

-h 

i— V 

\ 

i 

r~ 

i 

\- 

— 

\ 

/ 

r4 

450 

— 

=jt 

i 

-\- 

-f 

V 

/ 

400 

i 

/ 

y 

/ — 

3SO 

N 

300 

250 

TABLE  II.    Curz'e  of  actual  number  of  cases  of  diphtheria  in 
Boston,  by  the  month  for  iSS?-8j  inclusive. 


DIPHT- 
HERIA 

CROUP 

3 

i 

c 

I 

5 
i 
C 

> 

3 

o 
z 

1 

260  1.O0 
240  SO 
220  80 
200  70 

-4 

i 

H 

i 

N 

T 

1 

> 

ISO  60 
160  SO 
140  40 

120  30 
lOO  20 

4- 

1 

j 

i — 

- 

— 

/ 

- 

TABLE  III.    Curat  of  number  of  deaths  by  the  month  from 
Diphtheria  and  from  Croup.   fSSf-Sj.  inclusive. 
Diphtheria    C>vup  


478 


LOVETT,    JIUNRO,  TRACHEOTOMY. 


MONTHS 

z 

Feb. 

MARCH 

APRIL 

May 

JUNE 

JULY 

Aug. 

co 

OCT. 

j  Nov.  | 

|  Dec.  I 

36 

- 

r—j 

36. 

t 

4 

\l 

f 

4 

r\ 

h 

V- 

t 

-V- 

t 

4- 

4 

33 

T 

4- 

=t 

32. 

-j 

-V 

-J 

} 

- 

3.1 

t 

f 

I— 

! 

4 

I 

1- 

1- 

> — 

h 

] 

-> 

t — 

/■ 

-7 

P\ 

28 

21. 

26. 

25 

24 

TAJBLE  IV.    Curve  of 'mortality  percent  of  diphtheria. 

1881-83  incl.  Proportion  of  fatal  cases 
to  cases  reported. 


TABLE  V.     Curve  of  prevalence  of  scarlet  fever  by  the  month. 

1881-85  inclusive  Nu7iiber  of  cases  reported. 


REVIEWS. 


Autobiography  of  Samuel  D.  Gross,  M.D.,  D.C.L.  Oxon,  LL.D. 
Caiitab.,  Edin.,  Jeff.  Coll.,  Univ.  of  Pa.,  Emeritus  Professor  of  Surgery  in 
the  Jefferson  Medical  College  of  Philadelphia.  With  Sketches  of  his  Con- 
temporaries. Edited  by  his  Sons.  2  vols.  8vo.,  pp.  xxxii.  407,  438. 
Philadelphia:  George  Barrie,  1887. 

When  it  became  known,  soon  after  the  death  of  Professor  Gross,  that 
he  had  left  in  manuscript  for  publication  an  extended  autobiography, 
partly  in  the  form  of  a  diary,  which  he  had  kept  for  many  years  of  his 
busy  and  varied  professional  life,  a  laudable  curiosity,  and,  in  some 
quarters  possibly,  an  earnest  anxiety  was  awakened  to  see  its  contents, 
to  look  behind  that  veil  of  conventionalism  by  which  we  are  all  more 
or  less  concealed  from  view,  and  from  this  nearer  standpoint  to  become 
acquainted  with  the  nature  of  the  man  himself,  and  discover,  if  possible, 
the  sources  of  his  remarkable  influence  and  power. 

His  long-tried  friends,  who  followed  with  him  for  more  than  a  third 
of  a  century,  and  are  now  wearing  the  invisible  crape  of  sorrow  for  the 
loss  of  his  personal  presence,  will  here  find  the  reasons  for  the  faith 
which  was  in  them  clearly  transcribed,  and  can  point  with  commendable 
pride  to  indisputable  proofs,  if  such  were  needed,  of  the  manliness  of  his 
character,  the  truthfulness  of  his  nature,  his  generous  and  forgiving 
spirit,  and  the  unsullied  virtue  of  his  noble  life.  In  this  frank  disclosure 
of  the  thoughts  of  his  heart,  they  will  recognize  a  remarkable  corre- 
spondence with  his  walk  and  conversation,  and  be  convinced  that  the 
plane  upon  which  he  moved  was  of  even  greater  elevation  than  they  had 
supposed.  Those  who  were  once  his  enemies — and  of  these  it  is  deserving 
of  mention,  that  he  had  more  than  sufficient  in  number  to  exempt  him 
from  the  Scriptural  denunciation  of  those  of  whom  all  the  world  speak  well 
— who  in  the  earlier  stage  of  his  career  scoffed  at  him  from  the  roadside, 
but  who,  apparently,  led  by  the  desire  for  loaves  and  fishes,  subsequently 
joined  the  company  of  his  true  disciples,  and  thereafter  were  accustomed 
to  greet  him  with  a  widely  heard  "  Hail,  Master,"  when  they  met  him  in 
public  places,  will  be  also  greatly  gratified  to  learn  from  the  record, 
that,  not  doubting  the  sincerity  of  their  conversion,  he  admitted  some  of 
them  to  a  high  place  in  his  regard.  Those  who  persistently  continued 
in  their  jealous  opposition,  and  openly  resisted  his  advance  to  pro- 
fessional premiership,  if  any  such  remain,  will  be  sorely  disappointed 
in  their  search  here  for  even  so  much  as  mention  of  their  nanu  s. 

To  make  a  satisfactory  analysis  of  these  two  well-filled  and  admirably 
printed  volumes  would  require  the  construction  of  an  independent  biog- 
raphy, a  work  of  love  such  as  has  been  already  given  in  this  journal 
shortly  after  the  death  of  the  illustrious  author,  and  in  the  preliminary 
sketch  prepared  for  the  work  by  his  affectionate  friend,  the  late  Professor 


480 


REVIEWS. 


Austin  Flint,  Sr.,  M.D.  Brief  notices  arranged  somewhat  in  the  form 
of  a  narrative  of  some  of  the  more  prominent  features  of  the  work  is  all 
that  will  be  attempted  here. 

It  has  been  said  that  some  men  are  born  to  greatness  and  others  have 
greatness  thrust  upon  them.  To  neither  of  these  classes  did  Dr.  Gross 
belong.  He  was,  not  in  its  common  acceptation,  but  in  the  truest  sense 
of  the  phrase,  a  self-made  man ;  not  made  by  his  surroundings,  not 
forced  by  early  poverty,  privation,  neglect,  and  the  pressure  of  insur- 
mountable difficulties  upon  the  right  hand,  and  upon  the  left  to  pursue 
an  unselected  pathway  leading  to  an  unknown  country.  He  was  directed 
to  it  by  his  own  deliberate  choice,  when  other  and  apparently  easier 
routes  presented  themselves,  and  followed  it  assiduously  with  his  eyes 
fixed  upon  the  heights  which  ever  beckoned  him  upward.  The  story  is 
a  fascinating  one  from  the  beginning  to  the  end,  and  will  of  itself  greatly 
interest  the  reader,  without  considering  the  many  diversions  by  the  way ; 
but  it  can  be  learned  only  from  the  book  itself.  The  road  which  was 
somewhat  broken  and  circuitous,  and  in  places  rugged  and  precipitous, 
is  here  clearly  delineated.  In  imagination  one  can  almost  count  the 
steps  as  they  are  successively  surmounted,  while  the  exertion  of  the 
toiler  is  in  a  measure  lost  sight  of  in  the  interest  and  pleasure  with  which 
we  contemplate  the  steady  tread  by  which  he  gradually  but  surely  and 
with  encouraging  voice  passes  all  who  started  with  him,  many  of  them 
as  zealous  as  he  to  attain  the  elevation  upon  which  his  feet  alone  were 
destined  to  rest. 

He  tells  us  that  he  was  born  upon  the  8th  of  July,  1805,  of  Christian 
parents,  in  the  possession  of  a  fair  allowance  of  this  world's  goods,  and 
that,  notwithstanding  the  pleasures  and  distractions  of  boyhood,  he  early 
determined  upon  a  course  of  life  from  which  he  never  afterward  seriously 
swerved.  This  was  the  more  remarkable,  considering  that  he  lost  his 
excellent  father  when  only  seven  years  old,  and  his  education  was 
mainly  under  the  control  of  his  guardians. 

Riding,  fishing,  shooting,  swimming,  snaring  rabbits,  and  pitching 
pennies,  to  the  last  of  which  he  subsequently  ascribed  much  of  his  com- 
bined accuracy  of  eye  and  precision  of  hand,  were  the  principal  amuse- 
ments of  his  leisure  hours — of  which  he  seems  to  have  had  not  a  few, 
despite  the  earnestness  with  which  he  applied  himself  to  his  studies. 
And  here  we  see,  even  at  this  early  age,  an  exhibition  of  a  great  gift, 
the  power  of  combining  without  interference  work  and  relaxation,  which 
was  such  a  striking  picture  of  his  after-life.  In  this  he  resembled  von 
Humboldt,  Sir  James  Simpson,  Sir  Humphrey  Davy,  and  a  few  other 
fortunately  constituted  students,  who,  in  addition  to  the  performance  of 
an  enormous  amount  of  intellectual  and  practical  labor,  found  an  abun- 
dance of  time,  not  only  for  the  exacting  demands  of  the  fashionable, 
polite  society  in  which  they  moved,  but  also  for  indulgence  in  much 
unprofessional  reading,  and  many  innocent  amusements.  But,  notwith- 
standing his  frolicsome  nature,  and  the  zest  wTith  which  he  engaged  in 
all  the  diversions  of  a  boyhood  spent  in  the  country,  he  was  never  guilty, 
as  he  solemnly  assures  us  later  in  his  memoirs,  of  insobriety,  gambling, 
or  any  other  form  of  immorality. 

At  the  age  of  seventeen,  thinking  himself  sufficiently  instructed  to 
undertake  the  study  of  medicine,  he  entered  the  office  of  a  physician,  in 
Easton,  his  native  town,  and  was  set  to  work  at  once,  as  was  the  abomi- 
nable custom  at  that  day,  upon  old  and  obsolete  books  on  the  practice 


AUTOBIOGRAPHY    OF    SAMUEL   D.  GROSS.  481 

of  medicine,  surgery,  obstetrics,  anatomy,  etc.  He  had  the  good  sense 
soon  to  discover  that  this  was  not  the  proper  course  to  pursue,  and  also 
that  his  previous  education,  especially  in  Latin  and  Greek,  was  not 
extensive  enough  to  enable  him  to  comprehend  with  readiness  the  tech- 
nical terms  which  he  enountered  in  his  reading.  The  result  of  this 
discovery  is  thus  stated  : 

"  With  some  degree  of  hesitancy,  lest  I  should  give  offence,  I  disclosed  my 
feelings  to  my  preceptor,  and,  much  to  his  honor,  he  at  once  released  me  from 
any  obligation  to  serve  out  my  term  of  study.  TJiis  was  the  turning-point  in 
my  life.  I  had  pondered  the  matter  with  much  care ;  it  had  worried  and 
fretted  me  for  days  and  nights ;  and,  as  I  was  naturally  very  diffident,  it 
required  all  the  courage  I  could  summon  to  make  known  my  wishes.  The 
promptness  with  which  they  were  seconded  gave  me  such  relief  that  I  once 
more  drew  a  long  and  comfortable  breath.  I  had  made  a  great  discovery — a 
knowledge  of  my  ignorance,  and  with  it  came  a  solemn  determination  to 
remedy  it." 

He  therefore  resumed  his  preliminary  studies,  first  at  the  academy  in 
Wilkesbarre,  then  at  a  private  school  in  the  City  of  New  York,  and  sub- 
sequently at  the  high  school  at  Lawrenceville,  New  Jersey.  The  two 
years  thus  spent  were  devoted  mainly  to  the  acquirement  of  the  Greek 
and  Latin  languages,  to  which  were  added  mathematics  and  geography, 
and  a  large  amount  of  miscellaneous  reading.  His  piquant  sketches  of 
his  teachers,  and  the  relation  of  some  of  the  incidents  of  his  school-life, 
especially  his  visit  to  Trenton,  New  Jersey,  to  witness  the  arrival  of 
General  Lafayette,  who  was  then  (1824)  on  a  tour  through  this  country, 
make  very  pleasant  reading;  but  what  appears  to  us  most  remarkable 
is,  that  a  lad  of  seventeen  should  possess  the  wisdom,  and  exercise  the 
resolution,  to  suspend  his  professional  studies  in  order  to  supply  what 
he  considered  the  deficiencies  of  his  preliminary  education,  especially 
when  it  is  remembered  that  he  was  quite  the  equal,  probably  much  in 
advance,  of  any  of  his  companions  in  the  extent  and  accuracy  of  his 
scholastic  acquirements.  It  is  most  fortunate,  however,  that  this  dis- 
covery was  made  at  such  an  early  day,  as  it  is  usually  only  in  after-life 
that  the  eyes  of  most  men  thus  circumstanced  are  opened,  when  it  is  too 
late  to  correct  the  error. 

That  the  classical  training  which  he  experienced  during  these  two 
years  -was  of  incalculable  service  to  him  no  one  who  is  familiar  with  his 
writings  can  doubt ;  and  yet  it  is  due  to  the  truth  of  his  history  to  tell, 
what  is  not  mentioned  in  his  diary,  that  when,  in  1845,  a  pupil  in  his 
office  became  the  subject  of  similar  convictions,  and  consulted  him  as  to 
the  propriety  of  resorting  to  Transylvania  University,  a  noted  classical 
institution  at  Lexington,  Ky.,  he  advised  against  the  scheme.1  In  fact, 
it  would  seem  from  an  entry  made  July  18,  1883,  that  his  early  opinion 
as  to  the  necessity  and  special  advantage  of  the  acquirement  of  the  dead 
languages  preliminary  to  the  study  of  medicine,  or  any  other  profession 
save  theology,  underwent  some  modification.  This  is  not  the  place  to 
discuss  the  question,  but  we  may  be  allowed  to  express  the  hope  that 
the  views  of  Charles  Francis  Adams,  Jr.,  have  not  been,  and  may  never 
be,  generally  received  with  favor,  even  within  the  precincts  of  Harvard 
University. 

Having  secured  the  objects  of  the  temporary  suspension  of  his  pro- 


1  We  have  authority  for  sajing  that  the  pupil  [alluded  to  has  never  ceased  to  regret  his  acceptance 
of  the  advice. 

NO.  CLXXXVIII.  — OCTOBER,  1887.  31 


482 


REVIEWS. 


fessional  studies,  and  added  to  his  other  resources  a  fair  acquaintance 
with  mineralogy  and  the  French  language,  he  entered  the  office  of  Dr. 
Swift,  in  Easton,  in  1824,  and  began  seriously  that  unbroken  succession 
of  labors  which  ceased  only  with  his  death,  sixty  years  thereafter. 

In  October,  1826,  he  matriculated  in  Jefferson  Medical  College, 
Philadelphia,  then  in  the  third  year  of  its  existence,  and  became  the 
private  pupil  and  intimate  friend  of  its  founder,  George  McClellan,  M.D., 
Professor  of  Surgery.  In  consequence  of  the  bitter  opposition  of 
the  friends  of  the  University  of  Pennsylvania  to  the  "new  school" 
and  its  originators,  Professors  McClellan,  N.  R.  Smith,  Eberle,  Barton, 
Barnes,  and  Khees,  his  association  with  these  gentlemen  brought  upon 
him  the  ill-will  of  many  influential  men,  from  which,  in  a  hereditary 
form,  he  was  never  able  wholly  to  emancipate  himself  as  long  as  he 
lived.  But  for  this  it  is  probable  that  he  would  have  never  left 
Philadelphia ;  and  the  great  West,  where  he  spent  his  best  years,  would 
have  been  denied  the  vast  benefits  of  his  personal  presence  and  teaching. 

He  took  his  degree  in  the  spring  of  1828,  and  then  opened  an  office 
in  Philadelphia,  and  began  at  once  that  series  of  translations  of  French 
and  German  professional  works  upon  which  he  spent  most  of  the 
ensuing  eighteen  months.  His  practice  at  this  time  was  exceedingly 
meagre,  and  starvation  was  staring  him  in  the  face,  but  this  did  not 
deter  him.  On  the  contrary,  he  was  convinced  that  he  could  not  only 
provide  for  himself  but  for  another,  who  was  equally  brave  to  place 
herself  by  his  side  and  share  in  his  trials ;  and,  it  may  be  added,  that 
never  was  a  union  of  two  loving  hearts  productive  of  greater  mutual 
happiness. 

During  the  eighteen  months  he  spent  in  a  Philadelphia  boarding- 
house,  vainly  endeavoring  to  obtain  a  livelihood  by  the  practice  of  his 
profession,  he  made  the  acquaintance  of  a  number  of  gentlemen  who 
became  more  or  less  prominent  in  different  departments  of  work,  of 
whom  no  one  seemed  to  make  so  deep  an  impression  upon  his  mind  and 
heart  as  Dr.  John  D.  Godman,  the  anatomist,  naturalist,  and  author; 
the  account  of  whose  literary  and  scientific  pursuits,  as  lecturer  and 
writer,  his  desperate  but  futile  contest  with  poverty,  and  his  early  death, 
fills  two  or  three  of  the  most  interesting  pages  of  the  book. 

He  subsequently  removed  to  Easton,  and  there  he  found  the  more 
lucrative  field  he  sought,  but  it  must  not  be  supposed,  however,  that  his 
pen  was  allowed  to  rest  during  this  period  of  active  outdoor  work.  On 
the  contrary,  he  found  time  to  write  and  publish  a  large  octavo  volume 
entitled  The  Anatomy,  Physiology,  and  Diseases  of  the  Bones  and  Joints, 
and  a  complete  treatise  upon  descriptive  human  anatomy,  which  latter, 
however,  was  never  committed  to  the  press.  In  the  former  he  was  the 
first  to  call  attention  to  the  great  assistance  derived  from  the  use  of  ad- 
hesive plaster  in  the  treatment  of  fractures,  a  fact  which  he  had  observed 
in  the  practice  of  his  former  preceptor,  Dr.  Swift.  It  was  at  this  time 
also  that  he  was  elected  Professor  of  Chemistry  in  Lafayette  College,  at 
Easton,  Pennsylvania.  But  as  this  was  only  a  nominal  appointment, 
nothing  came  of  it.  Indeed  it  was  quite  evident  that  he  had  no  serious 
idea  of  occupying  a  chair,  for  the  duties  of  which  he  confessed  his  total 
lack  of  fitness. 

In  the  twenty-ninth  year  of  his  age  Dr.  Gross  entered  upon  his  long 
and  brilliant  career  as  a  public  teacher.  He  had  accepted  in  1833  the 
position  of  Demonstrator  of  Anatomy  in  the  Medical  College  of  Ohio, 
and  in  October  of  that  year  he  removed  to  Cincinnati. 


AUTOBIOGRAPHY   OF   SAMUEL   D.  GROSS. 


483 


And  here,  too,  began  that  series  of  annoyances — some  of  them  ranking 
as  positive  and  protracted  vexations — to  which  he  was  more  or  less  sub- 
jected through  the  envy  and  jealousy  of  open  enemies  and  false  friends, 
throughout  his  entire  stay  in  the  West.  We  do  not  desire  to  dwell  upon 
this  feature  of  his  experience,  but  as  it  had  an  important  bearing  upon 
his  subsequeut  history — as  may  be  clearly  shown  by  his  unpublished 
letters — and  may  serve  to  correct  the  inference,  which  is  likely  to  be 
drawn  from  the  perusal  of  these  pages,  that  his  professional  advances 
were  always  accomplished  under  a  cloudless  sky,  we  have  only  to  accom- 
pany him  to  Louisville,  Ky.,  whither  he  was  called  in  1840,  to  take  the 
chair  of  Surgery  in  the  Medical  Institute  of  that  city.  But,  not  to 
anticipate,  let  us  dwell  a  little  longer  upon  his  life  in  Cincinnati. 

In  1835  he  accepted  the  chair  of  Pathological  Anatomy  in  the  Medical 
Department  of  the  Cincinnati  College,  then  in  process  of  organization 
under  the  leadership  of  Dr.  Daniel  Drake,  who  was  already  a  noted 
teacher,  having  been  a  member  of  the  faculty  of  the  Medical  Depart- 
ment of  Transylvania  University,  at  Lexington,  Ky. ;  of  the  Medical 
College  of  Ohio,  of  which  he  was  the  founder ;  and  of  Jefferson  Medical 
College,  Philadelphia. 

Dr.  Drake,  who  was  his  senior  ,by  twenty  years,  and  a  man  of  very 
eccentric  disposition,  conceived  a  very  great  fancy  for  the  young  pro- 
fessor. This  was  fully  returned,  and  soon  ripened  into  an  intimate 
friendship,  which  flowed  on  with  increasing  volume,  and  scarcely  a 
ripple,  until  the  death  of  the  former  in  1852.  They  were  associated 
together  in  teaching,  not  only  in  Cincinnati,  but  subsequently,  for  many 
years,  at  Louisville,  where  they  formed  the  two  grand  pillars  of  the 
medical  college. 

Dr.  Gross's  success  in  Cincinnati,  as  a  teacher,  a  practitioner,  and  a 
leader  in  intellectual  and  polite  society,  was  almost  phenomenal ;  and 
when  he  left  there  a  sensible  void  was  produced  in  each  one  of  these 
circles.  He  gives  graphic  descriptions  of  many  of  the  noted  workers 
with  whom  he  became  acquainted  there,  such  as  Nicholas  Longworth, 
Lyman  Beecher,  Salmon  P.  Chase,  Bishop,  afterward  Archbishop, 
Purcell,  General,  afterward  President,  Harrison,  Bishop  Mcllvaine, 
Doctor  Gamaliel  Bailey,  Dr.  Drake,  and  others. 

While  here  he  wrote  his  great  work  on  Pathological  Anatomy,  which 
made  him  not  less  famous  abroad  than  in  his  own  country,  besides  several 
valuable  contributions  to  the  Western  Journal  of  the  Medical  and  Phys- 
ical Sciences.  It  wTas  at  this  time,  also,  that  he  was  offered  and  declined 
the  professorship  of  Medicine  in  the  University  of  Virginia,  and  the 
chair  of  Anatomy  in  the  University  of  Louisiana. 

The  Louisville  Medical  Institute,  afterward  called  the  Medical  Depart- 
ment of  the  University  of  Louisville,  was  founded  in  1836  (?)  by  a  seces- 
sion from  Transylvania  Medical  College,  consisting  of  Professors  Charles 
Caldwell,  John  Easton  Cooke,  Charles  W. Short,  and  Lunsford  P.  Yandell, 
who  added  to  their  number  Henry  Miller  and  Joshua  H.  Flint,  the  latter 
a  fresh  importation  from  Boston,  to  fill  the  chair  of  Surgery,  and,  three 
years  later,  the  illustrious  Dr.  Drake,  probably  the  most  brilliant  teacher, 
philosophical  thinker,  and  powerful  writer  that  the  medical  profession 
of  the  West  has  ever  produced.     Dr.  Flint,1  having  proved  an  utter 

1  It  is  scarcely  necessary  to  warn  the  reader  against  confounding;  with  this  gentleman  the  distin- 
guished Professor  Austin  Flint,  who  entered  the  school  some  years  later,  and  subsequently  obtained 
a  world-wide  reputation  as  a  teacher  aud  writer. 


484 


EE  VIEWS. 


failure,  was  compelled  to  retire  in  1840,  and  Dr.  Gross,  who  had  never 
been  engaged  in  teaching  surgery,  invited  to  occupy  the  vacant  chair. 
The  result  of  Dr.  Flint's  displacement  added  fuel  to  the  flame  of  bitter 
resentment  which  had  already  manifested  itself  on  the  part  of  a  large 
majority  of  the  physicians  of  the  city,  none  of  whom  had  been  invited 
to  assist  in  the  organization  of  the  school.  It  may  be  readily  imagined, 
therefore,  that  the  appearance  of  Dr.  Gross,  another  stranger,  upon  the 
scene  was  not  calculated  to  allay  the  excitement,  as  may  be  learned  from 
the  facts  stated  in  his  Autobiography,  and  confirmed  by  abundant  con- 
current testimony. 

Notwithstanding  the  triumph  he  soon  achieved,  the  feeling  of  hostility 
continued  with  more  or  less  force  during  his  entire  residence  in  the  city  ; 
and  such  is  the  cancerous  nature  of  enmity  originating  in  jealousy  and 
wounded  amour  propre,  that  some  who  were  thus  affected  cursed  the 
good  man  to  whom  they  viciously  ascribed  their  injury,  long  after  he 
personally  disappeared  from  their  view.  For  this  opposition  and  hatred 
he  was,  however,  more  than  compensated  by  his  great  success  as  a  lec- 
turer and  practitioner,  aud  the  numerous  ardent  friendships  which  he 
rapidly  contracted  with  the  best  citizens  of  the  town.  Indeed,  we  hazard 
nothing  in  saying  that  no  man,  whether  in  or  out  of  the  profession,  ever 
lived  in  Louisville,  or  possibly  within  the  limits  of  Kentucky — Henry 
Clay  alone  excepted — to  whom  so  many  people  became  so  strongly 
attached.  He  was  a  favorite  with  men,  women,  and  children,  rich  and 
poor,  white  and  black,  bond  and  free,  and  when,  at  the  end  of  sixteen 
years,  he  intimated  his  intention  to  remove  to  another  field  of  labor, 
the  whole  community  seemed  to  raise  their  hands  and  voices  in  earnest 
protest. 

It  should  not  be  forgotten  in  this  connection  that  Mrs.  Gross  was  in 
her  sphere  quite  as  successful  in  captivating  the  hearts  of  the  people  as 
her  illustrious  husband.  Her  urbane  manners,  her  intellectual  acquire- 
ments, her  sunny  temperament,  her  remarkable  powers  of  adaption,  and 
her  open-hearted  hospitality  rendered  her  parlors  a  rendezvous  of  agree- 
able and  intelligent  men  and  women  nearly  every  evening  in  the  week. 
Some  idea  of  the  powerful  influence  she  excited  upon  him  personally, 
and  the  great  consolation  which  she  afforded  him  in  the  midst  of  his 
many  cares  and  anxieties,  is  manifest  throughout  the  history  of  his 
entire  married  life.  He  loved  her  intensely,  admired  her  exalted  char- 
acter, and  was  proud  of  the  position  which  was  accorded  to  her  in  general 
society.  It  is  delightful  to  read  the  evidences  of  his  great  affection  for 
her  as  they  unconsciously  break  out  in  different  parts  of  the  record,  and 
inexpressibly  sad  to  witness  the  deep  grief  by  which  he  was  overcome, 
when,  in  1876,  she  was  laid  away  in  her  earthly  grave  at  Woodlands 
Cemetery,  Philadelphia.  The  high  enconiums  which  he  pronounces 
upon  her  in  the  later  pages  of  his  memoirs  are  fully  sustained  by  the 
undimmed  remembrance  of  her  surviving  friends.  She  was  a  noble 
Christian  woman,  and  added  lustre  to  the  name  and  fame  of  her  noble 
husband. 

Although  Professor  Gross  passed  the  best  years  of  his  life  in  Louis- 
ville— sixteen  in  number,  including  the  single  winter  he  spent  in  New 
York  as  Professor  of  Surgery  in  the  University  of  New  York — it  is  a 
little  singular  that  his  record  of  this  period  does  not  extend  beyond 
thirty-four  pages,  more  than  twenty  of  which  are  devoted  to  brief,  but 
interesting  notices  of  some  of  the  distinguished  people  with  whom  he 


AUTOBIOGRAPHY 


OF   SAMUEL  D.  GROSS. 


485 


became  acquainted  while  there.  The  list  of  these  includes  Henry  Clay, 
John  J.  Crittenden,  James  Guthrie,  James  P.  Espy — popularly  known  as 
the  "  Storm  King  "  ;  von  Raumer,  the  distinguished  German  historian- — 
of  whom  a  very  remarkable  incident  is  told  ;  Reverend  Robert  J.,  Win. 
C,  and  General  John  C.  Breckinridge ;  W.  J.  Graves,  the  well-known 
survivor  of  a  noted  duel  fought  with  Mr.  Cilley,  a  fellow-townsman, 
and  other  less-distinguished  characters.  He  also  tells  of  his  original 
investigations  in  wounds  of  the  intestines  by  means  of  numerous  experi- 
ments upon  dogs,  and  of  the  treatise  which  he  published  upon  this  subject ; 
of  the  composition  of  his  work  upon  Foreign  Bodies  in  the  Air- Passages, 
the  well-known  volume  upon  Diseases  and  Injuries  of  the  Bladder  and 
Urethra,  and  his  valuable  History  of  Kentucky  Surgery,  in  which  last  he 
disentombed  the  immortal  remains  of  Dr.  Ephraim  McDowell,  of  Dan- 
ville, the  almost-forgotten  originator  of  ovariotomy.  During  this  period 
he  also  contributed  liberally  to  the  pages  of  the  Western  Journal  of  Medi- 
cine; and,  after  the  death  of  this  periodical,  joined  Dr.  T.  G.  Richard- 
son in  establishing  the  Louisville  Review,  which  was  soon  afterward 
transferred  to  Philadelphia,  much  extended  in  its  scope,  and  published 
under  the  title  of  The  North  American  Medico-  Chirurgical  Review. 

It  is  remarkable,  however,  that  but  little  reference  is  here  made  to  his 
professional  life,  and  his  relations  to  his  colleagues.  It  is  true  that  he 
wrote  brief  memoirs  of  Caldwell,  Drake,  and  Miller  after  their  death, 
but  there  is  a  singular  omission  of  any  definite  account  of  one  or  more 
affairs  which  were  freely  discussed  in  the  public  prints  of  that  day,  and 
became  an  essential  part  of  the  history  of  the  medical  school.  Many  of 
the  readers  of  the  autobiography  might,  therefore,  suppose  that  there 
was  nothing  of  special  interest  to  relate  in  this  connection,  but,  on  the 
contrary,  there  is  good  reason  to  know,  from  personal  knowledge  of 
his  private  correspondence,  that  there  wTas  much  to  disturb  his  life,  and 
sufficient  in  its  unpleasantness  to  exert  a  decided  influence  upon  his 
decision  when  he  was  invited  to  take  the  chair  of  Surgery  in  the  City  of 
New  York,  and  subsequently  in  the  Jefferson  Medical  College  of  Phila- 
delphia. 

It  is  sad,  but,  unfortunately,  true,  that  in  the  history  of  medical  edu- 
cation in  this  country,  it  is  difficult  to  point  to  a  single  medical  faculty 
in  which  the  presence  of  inharmonious  elements  has  not  seriously 
marred  or  absolutely  destroyed  the  usefulness  of  these  institutions.  The 
too-popular  belief  that  the  profession  of  medicine  necessarily  engenders 
antagonisms  between  its  practitioners,  is  strongly  substantiated  by  the 
histories  of  our  medical  faculties ;  and  we  do  not  hesitate,  therefore,  to 
say  to  all  unfledged  public  teachers  of  medicine,  that  if  they  aspire  at 
the  same  time  to  lives  of  peacefulness,  they  are  upon  the  wrong  route. 
We  have  already  had  some  of  the  experiences  of  Professor  Gross  in  the 
Medical  College  of  Ohio  and  the  Cincinnati  Medical  College  related  to 
us,  but  we  miss  the  same  frank  expressions  in  regard  to  the  school  at 
Louisville.  This  institution  was  no  exception  to  the  others,  as  we  learn 
from  the  newspapers  of  the  time,  in  connection  with  the  shovelling  of 
Professor  Caldwell  out  of  the  faculty  in  1849.  Some  reference  is  made 
to  this  ugly  procedure  in  the  biographical  sketch  of  the  latter  just  alluded 
to,  but  the  very  strong  Anglo-Saxon  terms  in  which  our  author  then 
expressed  his  indignation  are  considerably  modified  in  the  text. 

As  we  have  already  seen,  Professor  Gross  accepted  the  chair  of  Sur- 
gery in  Jefferson  Medical  College  in  1856,  and  removed  the  same  year 


486 


REVIEWS. 


to  Philadelphia,  where  he  passed  the  remainder  of  his  days  in  com 
parative  quietude  of  mind,  and  the  active  pursuit  of  his  profession  as 
practitioner,  teacher,  and  writer.  His  distinction  as  a  surgeon  soon 
brought  him  patients;  and  notwithstanding  the  small  size  of  Phila- 
delphia fees — of  which  he  expresses  his  disapprobation  in  almost  con- 
temptuous terms— he  was  soon  in  receipt  of  an  income,  which,  added  to 
that  from  the  school,  made  him  quite  independent,  but  did  not  diminish 
the  laboriousness  of  his  daily  life.  His  literary  wrork  alone  would  have 
more  than  occupied  the  entire  time  of  almost  any  one  else,  to  which  the 
six  revised  editions  of  his  two  great  volumes  upon  General  Surgery 
(begun,  it  is  true,  in  Louisville);  the  revision  (or  rather  rewriting)  of 
his  book  upon  Pathological  Anatomy,  and  of  the  composition  of  his  work 
upon  Diseases  of  the  Urinary  Bladder,  etc.,  together  with  numberless 
smaller  contributions,  bear  ample  testimony.  Except  for  his  vigorous 
bodily  constitution,  his  well-trained  mind,  and  his  habits  of  regularity 
and  sobriety — and,  we  may  add,  his  cheerfulness  of  disposition — his 
years  would  certainly  have  been  much  shortened.  As  it  was,  he  con- 
tinued to  teach  until  he  was  seventy- seven  years  of  age,  and  did  not 
intermit  his  daily  labors  until  his  death,  two  years  later.  As  before 
stated,  his  professional  relations  were,  for  the  most  part,  of  an  unusually 
agreeable  nature ;  and  as  he  outlived  all  his  original  colleagues,  he  has 
embalmed  their  pleasant  memories  with  those  of  numerous  other  friends 
in  biographical  sketches,  which  appear  at  the  close  of  the  second  volume. 

The  account  which  he  here  gives  us  of  his  private  life,  his  food, 
drink,  and  sleep,  his  amusements,  his  methods  of  work,  his  religion,  his 
miscellaneous  reading,  his  manner  of  entertaining  his  friends,  and  the 
sketches  which  he  furnishes  of  the  different  members  of  his  family,  espe- 
cially his  much-loved  wife,  and  of  numerous  friends  and  distinguished 
strangers  who  partook  of  his  generous  hospitality  from  time  to  time,  are 
most  entertaining  and  instructive,  but  must  be  read  in  his  own  well- 
chosen  words  to  be  appreciated.  He  talks  upon  almost  every  conceiv- 
able subject  of  popular  and  scientific  interest,  evolution,  religion,  public 
amusements,  politics,  pistols,  longevity,  pictures,  natural  scenery,  mar- 
riage, etc.  (the  list  is  made  at  random),  including  matters  of  a  much 
more  professional  character. 

To  most  readers,  however,  his  more  or  less  extended  notices  of  public 
men  will  probably  prove  most  attractive.  These  occupy  not  less  than 
three-fourths  of  the  record  made  after  his  removal  to  Philadelphia,  not 
counting  the  forty-seven  distinct  biographical  sketches  just  referred  to  as 
appended  to  the  second  volume.  There  was  not  a  man  of  distinction  of 
any  department  of  life,  whether  in  this  country  or  abroad,  with  whom 
he  came  in  contact,  of  whom  something  has  not  been  jotted  down,  and 
more  or  less  amplified.  Some  of  these  sketches,  especially  those  of  Drs. 
Drake,  Dunglison,  Sims,  Hays,  Mott,  and  Meigs,  Archbishop  Wood,  and 
Mr.  Carey,  are  permeated  by  the  aroma  of  true  heartfelt  affection,  and 
are  written  in  his  best  style.  The  one  devoted  to  Dr.  Drake  fills  a 
dozen  pages,  and  is  a  worthy  tribute  of  admiration  and  love  to  one  of 
the  most  remarkable  men  which  the  medical  profession  of  this  country 
has  yet  produced. 

Profe-sor  Gross  visited  Europe  for  the  first  time  in  1868.  He  was 
then  in  his  sixty-third  year,  and  at  the  zenith  of  his  fame.  He  was,  of 
course,  received  with  open  arms  by  the  leading  men  of  the  profession 
wherever  he  went,  and  every  possible  means  of  pleasure  and  instruction 


AUTOBIOGRAPHY   OF   SAMUEL   D.  GROSS. 


487 


placed  at  his  disposal.  His  account  of  this  visit  occupies  more  than  a 
hundred  pages,  and  is  replete  with  most  interesting  comments  upon 
places  and  people.  In  his  wanderings  upon  the  continent,  no  single 
spot  seems  to  have  delighted  him  more  than  the  old  town  of  Berne,  in 
Switzerland,  the  interest  in  which  centred  in  the  house  in  which  Albert 
von  Haller  lived  for  many  years,  and  in  which  he  finally  died.  From 
the  time  he  began  the  study  of  medicine  he  was  a  great  admirer  of  the 
celebrated  Swiss  physiologist,  and  evinced  his  regard  by  giving  the  name 
to  his  youngest  son,  now  a  well-known  lawyer  and  litterateur  of  Phila- 
delphia, and  joint  editor  with  his  distinguished  brother,  Professor  S.  W. 
Gross,  in  the  editorship  of  these  memoirs. 

In  Vienna,  Rokitansky,  the  celebrated  pathological  anatomist,  was 
found  in  his  workshop,  surrounded  by  his  pupils,  and  in  the  midst  of  a 
necroscopic  examination.  Indeed,  it  is  difficult  to  conceive  of  this 
wonderful  worker  being  found  anywhere  else,  considering  that  he  has 
made  not  less  than  fifty  thousand  such  examinations;  and  yet,  we  are 
told,  that  "  he  finds  leisure  to  frequent  the  opera  and  the  concert,  and 
to  give  social  entertainments,  especially  musical  soirees,  being  very  fond 
of  music  and  a  good  performer  on  the  flute." 

Billroth,  the  famous  surgeon,  was  equally  cordial,  and  invited  him 
into  his  lecture-room,  where  he  was  engaged  in  what  appears  to  have 
been  an  utterly  useless  exsection  of  a  cancerous  rectum ;  and  while  he 
impressed  his  visitor  as  being  a  man  of  unusual  ability,  great  resources, 
and  large  capacity  for  labor,  he  did  not  captivate  him  by  his  bold  and 
almost  reckless  use  of  the  scalpel.  Dr.  Gross  adds  to  his  lively  descrip- 
tion of  the  man — "  Billroth  is  a  good  liver,  fond  of  society,  a  composer, 
and  a  superior  pianist ;  in  a  word,  a  remarkable  person,  such  as  is  rarely 
found  in  any  profession." 

In  Berlin,  he  called  first  upon  Virchow,  who  was  also  engaged  in 
making  a  pathological  demonstration  upon  a  cadaver,  but  stopped  to 
salute  him  and  introduce  him  to  the  class,  and  after  the  lecture  showed 
him  through  his  extensive  and  thoroughly  equipped  laboratory  and 
museum,  exhibited  his  large  collection  of  infantile  syphilitic  hearts  and 
livers,  and  explained  his  thorough  and  painstaking  method  of  practical 
teaching  by  means  of  the  scalpel  and  microscope.  As  is  well  known, 
Virchow  is  also  a  statesman  of  the  republican  school,  and  a  leading 
member  of  the  Reichstag.  He  gave  Professor  Gross  a  large  entertain- 
ment, which  was  succeeded  by  the  following  remarkable  exhibition  of 
regard  : 

"  After  the  viands  were  pretty  well  disposed  of,  our  host,  availing  himself 
of  a  lull  in  the  conversation,  drew  forth  a  large  volume  from  under  the  table, 
and  rising  he  took  me  by  the  hand,  and  made  me  an  address  in  German, 
complimenting  me  upon  my  labors  as  a  pathological  anatomist,  and  referring 
to  the  work,  which  happened  to  be  the  second  edition  of  my  Elements  of 
Pathological  Anatomy,  as  one  from  the  study  of  which  he  had  derived  much 
useful  instruction,  and  one  which  he  always  consulted  with  much  pleasure. 
I  need  not  say  how  deeply  flattered  I  felt  by  this  great  honor,  so  unexpectedly 
and  so  handsomely  bestowed  upon  me  by  this  renowned  man.  I  felt  that  I 
had  not  labored  in  vain,  and  that  the  compliment  was  more  than  an  equivalent 
for  all  the  toil  and  anxiety  which  the  work  had  cost  me." 

Von  Langenbeck  was  unremitting  in  his  polite  attentions : 

"He  invited  me  to  his  house,  showed  me  everything  about  his  hospital, 
introduced  me  to  his  class,  and  took  special  pains  to  perform  upon  the  dead 


488 


REVIEWS. 


subject  some  operations  in  which  he  had  acquired  unusual  distinction.  As 
an  operative  surgeon  he  enjoys  an  unrivalled  reputation  on  the  Continent  of 
Europe ;  and  it  is  questionable  whether  he  has  ever  had  a  superior  in  this 
branch  of  the  healing  art  anywhere — Dupuytren,  Lisfranc,  Mott,  Liston, 
Syme,  and  Fergusson  not  excepted.  ...  In  visiting  his  wards  he  pointed 
out  to  me  three  cases  of  excision  of  the  shoulder,  two  of  the  elbow,  one  of  the 
wrist,  one  of  the  hip,  one  of  the  knee,  and  two  of  the  ankle,  together  with  one 
of  the  shaft  of  the  humerus,  and  one  of  both  bones  of  the  leg.  ...  In  all 
such  operations,  as  well  as  in  recent  fractures,  whether  simple  or  compound, 
he  applies  at  once  a  thick,  immovable  plaster-of-Paris  splint,  provided  with 
fenestra  for  drainage." 

His  next  call  was  upon  von  Grafe,  and  the  account  which  he  gives 
of  this  remarkable  man,  his  general  appearance,  his  beautiful  counte- 
nance, his  winning,  child-like  manners,  his  great  benevolence  of  char- 
acter, his  style  of  lecturing,  his  mode  of  operating  for  cataract,  and  the 
vast  amount  of  work  which  he  performed  from  day  to  day,  is  given  with 
a  vigor  and  terseness  worthy  of  a  Macaulay.  It  is  sad  to  know  that  this 
great  ophthalmic  surgeon,  the  reputation  of  whose  judgment  and  skill 
had  already  reached  the  furthest  corner  of  the  civilized  world,  was 
removed  by  death  two  years  afterward  (1870)  in  the  forty-second  year 
of  his  age. 

It  was  here,  also,  that  Professor  Gross  saw  the  famous  microscopist, 
C.  G.  Ehrenberg,  blind  and  superannuated,  to  whom  he  bore  a  letter  of 
congratulation  from  the  American  Medical  Association,  which  was  after- 
ward published  in  a  pamphlet  along  with  similar  testimonials  from 
Agassiz,  Gould,  Dana,  Torrey,  and  other  distinguished  scientists,  and 
also  a  poem  addressed  to  him  by  Oliver  Wendell  Holmes. 

From  Prussia  Professor  Gross  crossed  the  British  Channel,  and  hur- 
ried through  London  to  Oxford,  to  be  present  at  the  annual  meeting  of 
the  British  Medical  Association,  where  he  met  for  the  first  time  Sir 
James  Paget,  Professor  Rolleston,  Mr.  Curling,  and  others  of  like  stand- 
ing, to  whom  he  was  already  well  known  by  correspondence  and  repu- 
tation. Thence  he  proceeded  to  Cambridge,  and  on  to  Norwich,  where 
the  British  Association  for  the  Advancement  of  Science  was  then  in 
session,  and  where  he  had  the  pleasure  of  shaking  hands  with  Sir  James 
Y.  Simpson,  J.  Hughes  Bennett,  Broca,  Baker,  Humphrey,  Partridge, 
and  others,  by  all  of  whom  he  was  treated  with  marked  distinction.  At 
Edinburgh  he  was  handsomely  entertained  by  Mr.  James  Syme,  than 
whom,  in  his  opinion,  Scotland  has  probably  produced  no  other  so  great 
a  surgeon  in  recent  times.  While  here  he  was  also  treated  with  the 
greatest  kindness  and  hospitality  by  Sir  James  Y.  Simpson,  who  made  a 
very  deep  impression  upon  him,  not  only  by  his  extraordinary  personal 
appearance,  but  by  his  charming  conversational  gifts,  his  great  mental 
activity,  the  great  variety  of  his  acquirements,  and  his  earnest  devotions 
to  the  truths  of  the  Christian  religion  as  set  forth  in  the  Holy  Scriptures. 

In  Dublin  he  saw  Stokes,  Adams,  Corrigan,  Tufnal,  Collis,  and  others. 
Of  all  these  famed  physicians  and  surgeons  he  gives  us  brief  and  often 
life-like  descriptions,  along  with  mention  of  the  particular  work  to  which 
their  lives  are  devoted.  Upon  his  return  to  Philadelphia,  after  an 
absence  of  five  months,  a  large  public  reception  was  given  to  him,  jointly 
with  Dr.  Pancoast,  by  their  professional  friends. 

He  repeated  his  visit  to  England  in  1872,  accompanied  by  Mrs.  Gross 
and  their  son  Haller,  mainly  to  be  present  at  Oxford  on  the  thousandth 
Commemoration  Day  of  the  University,  and  to  receive  the  degree  of 


AUTOBIOGEAPHY   OF  SAMUEL   D.  GROSS.  489 

D.C.L.  He  gives  a  pleasing  account  of  the  ceremony,  in  which  the  same 
honor  was  conferred  upon  Prince  Hassan  (of  Egypt),  Dr.  George  Burrows, 
and  Sir  Benjamin  Brodie  (chemist),  with  sketches  of  these  and  several 
other  noted  men  whom  he  met  there,  together  with  an  outline  of  the 
remarkable  history  of  the  University.  In  London  he  was  entertained 
most  hospitably,  visited  with  great  interest  St.  Thomas's  and  King's  Col- 
lege Hospitals,  listened  to  the  Harvein  oration  by  Dr.  Farre,  was  present 
at  the  anniversary  dinner  of  the  Royal  College  of  Physicians,  and  sub- 
sequently of  the  Fellows  of  the  Royal  College  of  Surgeons,  upon  all 
which  occasions  he  received  marked  attention,  which,  however,  is  only 
incidentally  referred  to  in  the  narrative. 

The  next  chapter,  the  XlVth,  in  the  volume,  containing  less  than 
thirty  pages,  embraces  a  period  of  nearly  five  years,  and  we  cannot  help 
thinking  that  large  omissions  have  been  made  here  by  the  editors.  Less 
than  two  pages  are  devoted  to  the  meeting,  in  1876,  of  the  Centennial 
Medical  Congress,  the  organization  of  which  we  know,  from  other  sources, 
was  not  accomplished  without  some  heart-burnings  and  jealousies. 

We  have  here  a  notice  of  the  meeting  of  the  American  Public  Health 
Association  in  Philadelphia  in  1874,  at  which  he  introduced  resolutions 
petitioning  Congress  to  establish  a  National  Bureau  of  Health,  with 
branches  at  the  seat  of  each  State  and  Territorial  Government.  He 
supported  these  resolutions  by  a  short  but  striking  address,  and  they 
were  unanimously  passed,  but  with  what  result  we  need  not  stop  here  to 
indicate,  as  the  object  is  only  to  show  that  he  was  the  author  of  the 
plan  adopted  in  part  by  Congress  four  years  later,  in  the  creation  of 
the  National  Board  of  Health,  a  scheme  which  met  with  most  ungen- 
erous treatment  by  many  members  of  the  medical  profession,  some  of 
the  medical  journals,  and  not  a  few  politicians,  with  the  effect,  as  every- 
body knows,  of  practically  crushing  it  out  of  existence  in  a  very  little 
while  after  it  was  put  in  force. 

But  the  most  marked  feature,  in  this  chapter,  is  the  account  of  the 
sickness  and  death  of  Mrs.  Gross,  in  February,  1876,  and  a  short  sketch 
of  her  life  and  character.  He  delights  to  dwell  upon  her  excellent 
qualities  as  wife  and  mother,  her  Christian  principles,  her  intellectual 
attainments,  her  cheerfulness  of  spirits,  and  her  remarkable  adapta- 
bility to  the  personal  varieties  of  society.  It  is  refreshing  and  beau- 
tiful to  see  with  what  tenderness  he  clings  to  her  memory  in  his  after- 
life. 

In  the  record  for  1877  we  find  first  a  notice  of  four  or  five  pages  in 
length  of  Sir  William  Fergusson,  who  died  in  February.  He  analyzes 
his  qualities  as  lecturer,  operator,  and  writer,  and  ascribes  his  fame 
mainly  to  his  dexterity  with  the  knife.  Next  comes  an  account  of  a 
visit  to  Baltimore  and  Washington,  and  the  people  he  met.  Then  his 
attendance  at  Chicago  upon  the  meeting  of  the  American  Medical  Asso- 
ciation. And  lastly,  a  visit  to  Boston  to  be  present  at  the  commence- 
ment of  Harvard  University.  Here  he  met  and  describes  his  friends, 
Drs.  Bowditch,  J.  B.  S.  Jackson,  and  E.  H.  Clark,  and  called  upon  Dr. 
Jacob  Bigelow,  who  was  then  in  his  ninety-second  year,  blind  and  bed- 
ridden, to  whom  he  ascribes  merits,  both  professional  and  private,  of  the 
highest  order. 

The  record  for  1878  is  largely  occupied  with  reminiscences  of  medical 
men,  such  as  Drs.  L.  P.  Yandell,  Washington  L.  Atlee,  and  J.  B.  S. 
Jackson,  all  of  whom  had  just  died,  and  Drs.  Can*  Lane,  William  Beau- 


490 


REVIEWS. 


mont,  and  Charles  A.  Pope,  all  three  of  St.  Louis,  the  last  mentioned 
one  of  his  private  pupi's,  and  a  man  of  brilliant  parts,  large  acquire- 
ments, and  distinguished  abilities  as  a  teacher  and  practitioner  of 
surgery. 

The  following  year  is  marked  by  two  notable  events.  First,  the  com- 
plimentary dinner  given  to  him  by  the  physicians  of  Philadelphia,  in 
commemoration  of  the  fifty-first  year  of  his  professonal  life ;  and,  second, 
his  address,  at  Danville,  Ky.,  at  the  dedication  of  the  monument  erected 
by  the  State  Medical  Society  in  honor  of  Dr.  Ephraim  McDowell.  The 
dinner  was  a  very  grand  affair,  but  as  an  account  of  it  was  soon  after- 
ward printed  and  privately  circulated  by  the  committee  of  management, 
it  is  only  necessary  to  quote  his  words  to  the  effect,  "  That  there  have 
been  more  costly  and  elaborate  dinners,  but  there  never  has  been  one 
in  which  there  was  more  rational  enjoyment,  or  in  which  a  more  cordial 
and  tender  feeling  was  manifested  for  the  man  whom  it  was  designed  to 
honor." 

During  this  year,  while  in  attendance  upon  the  meeting  of  the  Amer- 
ican Medical  Association  at  Atlanta,  he  attempted  to  organize  the  Con- 
vention of  Medical  Colleges  which  had  been  called,  at  his  instance,  the 
year  before,  by  the  American  Medical  College  Association,  for  the  pur- 
pose of  pledging  the  colleges,  or  a  majority  of  them,  to  certain  improve- 
ments in  teaching,  more  particularly  in  the  way  of  demanding  a  certain 
grade  of  preliminary  acquirements,  and  increasing  the  requirement  of 
attendance  upon  lectures  from  two  courses  to  three.  This  meeting, 
from  which  he  "  had  originally  expected  so  much,  adjourned  sine  die  at 
the  close  of  the  second  day's  proceedings,  thus  ending,  like  its  two  pre- 
decessors, in  '  smoke.' " 

The  entries  of  1880  occupy  sixty  pages,  and  are  full  of  interest,  but, 
unfortunately,  they  must  be  passed  over  here  with  but  bare  notices  of 
their  contents.  First  there  are  charmingly  written  reminiscences  of  Drs. 
John  Kearny  Rodgers,  David  Hosack,  and  John  W.  Francis,  all  of  New 
York,  and  long  since  dead — the  last  to  go  was  Dr.  Francis,  in  1881. 

Next  comes  an  account  of  his  visit  to  New  Orleans.  He  was  present 
at  the  commencement  of  the  Medical  Department  of  the  University  of 
Louisiana,  on  which  occasion,  in  some  remarks  he  made  to  the  graduates, 
he  characterized  the  late  Dr.  Stone  as  the  "  Great  Commoner  "  of  his  pro- 
fession, as  Henry  Clay  was  in  politics.  While  in  the  city  he  was  enter- 
tained at  a  public  dinner  given  to  him  by  the  two  local  medical  societies, 
and  was  treated  with  profuse  hospitality  at  several  private  houses.  He 
was  very  particular  to  call  upon  the  widows  of  Drs.  Charles  A.  Luzen- 
berg  and  Warren  Stone,  and  gives  graphic  descriptions  of  the  interviews, 
and  reminiscences  of  these  two  distinguished  surgeons. 

After  his  return  to  Philadelphia,  he  proceeded  to  New  York  to  attend 
the  meeting  of  the  American  Medical  College  Association  and  the 
American  Medical  Association.  He  was  President  of  the  former,  and 
was  much  elated  by  its  adoption  of  a  resolution  requiring  the  attendance 
of  three  courses  of  lectures  obligatory  upon  the  student  before  becoming 
a  candidate  for  graduation. 

''This  important  regulation  is  to  go  into  operation  in  1882-83,  and  there 
is  little  doubt  in  my  mind  that  it  will  be  generally  adopted  by  the  schools  of 
the  country  by  that  time.  When  this  object,  so  long  prayed  for  by  the  leading 
physicians  of  the  country,  as  well  as  by  many  of  our  more  intelligent  laymen, 
shall  be  attained,  the  nation  will  have  cause  to  congratulate  itself  upon  an 
event  which  cannot  fail  to  be  of  vast  benefit  to  it." 


AUTOBIOGRAPHY   OF   SAMUEL   D.  GROSS. 


491 


The  failure  of  nearly  all  the  schools,  including  the  one  of  which  he 
himself  was  the  most  distinguished  professor,  to  adopt  this  course,  was, 
subsequently,  a  source  of  great  sorrow  to  him  as  well  as  to  many  others 
who  had  labored  with  him  to  effect  this  great  advance  upon  our  present 
system  of  medical  teaching. 

After  the  adjournment  of  the  American  Medical  Association,  he  suc- 
ceeded in  organizing  the  American  Surgical  Association,  initiated  by 
him  the  previous  year  at  Atlanta,  and  for  which  he  had  made  every 
preparation  by  correspondence  and  personal  interviews  with  many  of  the 
leading  surgeons  of  the  country.  He  was  greatly  mortified,  however, 
when  he  found  that  the  surgeons  of  New  York,  with  possibly  one  excep- 
tion, held  aloof  from  the  movement.  He  was  made  President,  and  lived 
long  enough  to  see  the  Association  under  -full  headway,  and  with  the 
prospect  of  a  successful  and  brilliant  career.  He  was  elected  by  acclama- 
tion to  the  presidency  for  two  succeeding  years  when  he  positively 
refused  to  accept  the  position  again. 

A  few  weeks  later,  July  7th,  we  find  him  again  embarking  for  Eng- 
land, this  time  to  receive  from  the  University  of  Cambridge,  along  with 
eleven  others,  the  honorary  degree  of  Doctor  of  Laws,  the  highest  in 
her  gift,  and  to  attend  the  meeting  of  the  British  Medical  Association. 
The  conferring  of  the  degree  was  accompanied  by  a  good  deal  of  solemn 
and  impressive  ceremony. 

After  the  numerous  hospitalities,  which  continued  for  several  days 
succeeding  the  grand  ceremony,  Professor  Gross  and  his  son  returned  to 
London,  and  thence  to  America,  having  been  absent  scarcely  two  months. 
Considering  that  he  was  then  in  his  seventy-sixth  year,  it  is  not  surpris- 
ing that  the  numerous  entertainments,  breakfasts,  luncheons,  dinners, 
and  suppers  which  he  was  compelled  to  attend  during  his  stay  in  Eng- 
land, and  six  days'  severe  seasickness  on  the  voyage  back,  should  have 
pretty  nearly  put  an  end  to  his  powers  of  endurance,  and  rendered  his 
entrance  into  his  own  quiet  house  one  of  the  happiest  events  of  his  long 
life.  This  desire  for  rest,  of  which  he  then  felt  the  need  more  than  ever 
before,  may  possibly  account  for  the  fact  that  we  hear  nothing  more  from 
him  for  seven  months,  when,  on  April  3,  1881,  he  has  just  received  a 
letter  from  Sir  William  MacCormac,  Secretary,  inviting  him  to  deliver 

an  address  at  the  ensuing  meeting,  in  August,  of  the  International 

.  .. 

Medical  Congress,  in  London.  He  was  obliged  to  decline  in  consequence 
of  age  and  the  dread  of  seasickness,  but  suggested  the  names  of  five 
American  physicians,  of  whom  Dr.  Billings  was  selected.  We  need  not 
stop  to  descant  upon  the  wisdom  of  the  choice,  nor  upon  the  distinguished 
ability  with  which  the  honor  Avas  in  due  time  sustained. 

This  year,  1882,  is  specially  marked  by  his  resignation  of  the  chair  of 
surgery  in  the  Jefferson  Medical  College,  which  position  he  had  held  for 
twenty-six  years.  He  was  succeeded,  as  is  well  known,  by  his  son,  Dr. 
S.  W.  Gross,  as  Professor  of  Principles  of  Surgery,  and  Dr.  J.  H. 
Brinton,  Professor  of  Practice  of  Surgery. 

In  November,  Professor  Gross  attended  a  large  reception  given  to 
him  in  New  York,  by  Dr.  J.  Marion  Sims  and  his  son  H.  Marion  Sims. 
Two  or  three  hundred  distinguished  guests,  many  of  these  not  members 
of  the  medical  profession  and  drawn  from  several  of  the  adjacent  cities, 
were  present.  The  account  of  this  grand  entertainment,  probably  the 
most  brilliant  of  its  kind  ever  given  in  this  country  by  one  private 
gentleman  to  another,  is  more  than  modestly  brief,  but  it  is  followed  by 


492 


REVIEWS. 


an  extended  biographical  sketch  of  Dr.  Sims,  prompted  by  the  author's 
warmest  regard  and  admiration,  and  written  in  his  most  effective  style. 

"When  the  history  of  American  Medicine  shall  be  written,"  he  says, 
"  one  of  its  brightest  pages  will  be  an  account  of  the  services  of  Dr.  Sims, 
a  name  as  enduring  as  the  hills  and  valleys  of  South  Carolina,  his  native 
State." 

In  March  of  the  next  year  Professor  Gross  accepted  an  invitation  to 
deliver  the  valedictory  address  to  the  graduating  class  of  Bellevue  Hos- 
pital Medical  College,  New  York,  in  the  course  of  which  address  he 
strenuously  urges  the  young  men  to  study  carefully  the  American  code 
of  medical  ethics,  and  to  direct  their  lives  in  accordance  with  its  sacred 
teachings. 

The  next  thirty  to  forty  pages  of  the  second  volume  are  devoted 
mainly  to  short  biographical  notices.  Austin  Flint,  Sr.,  he  denominates 
the  American  Laennec,  and  places  him  in  the  first  rank  of  medical 
teachers,  writers,  and  practitioners.  Of  Oliver  Wendell  Holmes  he 
expresses  the  common  opinion  that  his  fame  as  a  contributor  to  the 
literature  of  the  country  has  so  completely  overshadowed  acknowledged 
abilities  as  professor  of  anatomy  that  it  is  hardly  necessary  to  speak  of 
the  latter. 

Passing  over  his  attendance  at  the  annual  meeting  of  the  American 
Surgical  Association  at  Cincinnati,  where  he  was  made  sad  by  observing 
that  all  the  old  landmarks  of  the  city  had  been  obliterated  since  he  came 
there  forty-three  years  before  to  take  the  position  of  Demonstrator  of 
Anatomy  in  the  Medical  College  of  Ohio,  and  over  his  subsequent 
attendance  upon  the  meeting  of  the  American  Medical  Association  at 
Cleveland,  Ohio,  we  come  to  an  excellent  disquisition  upon  marriage,  and 
some  of  the  more  frequent  causes  of  discontent  between  man  and  wife. 
He  tells  what  a  perfect  wife  should  be,  but  fails  to  describe  the  perfect 
husband. 

Next  is  a  brief  statement  of  his  views  upon  the  subject  of  cremation, 
and  the  impetus  which  his  example  has  given  to  this  procedure  has  been 
felt  in  all  parts  of  the  country,  and  will  probably  not  spend  itself  until 
there  has  been  a  complete  revolution  of  popular  sentiment,  in  cities  at 
least,  in  regard  to  the  proper  disposition  of  the  dead. 

The  year  closes  with  an  account  of  the  origin  of  the  famous  Wistar 
Parties  in  Philadelphia,  which  were  suspended  in  consequence  of  the 
civil  war,  and  have  been  but  lately  resumed ;  and  with  a  notice  of  the 
life  and  character  of  the  late  Dr.  Thomas  S.  Kirkbride,  the  celebrated 
alienist,  and  of  Professor  Sophocles,  of  Harvard  University. 

The  entries  made  in  1884  comprise  a  number  of  reminiscences,  and 
close  with  a  copy  of  a  formal  invitation  which  he  himself  had  just 
received,  inviting  him  to  Edinburgh  to  receive  the  honorary  degree  of 
Doctor  of  Laws  from  the  renowned  University,  and  which  he  was  com- 
pelled to  decline  in  consequence  of  his  inability  to  make  the  journey. 
Here  the  diary  ceases,  but  the  story  of  the  few  remaining  days  of  his 
life,  which  went  out  on  May  6th,  is  given  in  the  preliminary  memoir  of 
the  late  Professor  Austin  Flint,  Sr. 

Our  task  is  ended,  and  we  feel  that  we  have  fallen  far  short  of  even 
a  fair  analysis  of  these  two  deeply  interesting  volumes.  We  have  made 
no  comments  upon,  nor  even  given  a  list  of  Professor  Gross's  contribu- 
tions or  armamentarium  of  surgery,  nor  have  we  eulogized  him  as  we 


SNEGUIREFF,  UTERINE 


HEMORRHAGES. 


493 


might  as  teacher,  writer,  and  practitioner.  To  attempt  the  former  seemed 
out  of  place,  the  latter  would  have  been  unnecessary  and  superfluous. 
All  that  we  can  hope  is,  that  we  have  awakened  a  desire  upon  the  part 
of  many  of  our  readers  to  procure  the  book  and  read  it  carefully  from 
beginning  to  end.  The  private  record  of  so  good  and  great  a  man,  and 
so  distinguished  a  surgeon  as  Professor  Gross,  is  certainly  worthy  of  the 
closest  study,  and,  were  he  living,  nothing  would  rejoice  his  heart  so 
much  as  to  know  that  the  contemplation  of  his  life  from  this  standpoint 
had  reanimated  the  weak  and  halting  principles  of  medicine,  encouraged 
the  young  and  ambitious  aspirant,  and  added  steadiness  of  mind  and 
gait  to  those  who  are  already  far  advanced  upon  the  ever-ascending  road 
to  professional  fame. 

In  conclusion,  we  earnestly  commend  the  careful  perusal  of  the  work, 
not  only  to  the  profession,  which  was  honored  by  the  adoption  and  en- 
riched by  his  incessant  and  well-directed  labors,  but  to  the  general 
public,  as  the  record  of  a  life  devoted  to  the  best  interests  of  the  human 
race,  and  the  welfare  of  every  living  creature.  T.  G.  R. 


Hemorrhagies  Uterines,  Etiologle,  Diagnostic,  Traitement.  Par 
le  Docteur  Sneguireff,  Professeur  de  Gynecologie  a  l'Universite  Impe- 
riale  de  Moscou.  Edition  Francaise  redigee  par  M.  H.  Varnier,  Interne 
des  Hopitaux  de  Paris,  sous  la  direction  de  M.  le  Docteur  Pinard,  Pro- 
fesseur Agrege  a  la  Faculte  de  Paris,  Accoucheur  de  l'Hopital  Laraboisiere. 
Paris :  G.  Steinheil,  Editeur,  1886. 

The  Etiology,  Diagnosis,  and  Treatment  of  Uterine  Hemorrhages. 
By  Doctor  Sneguireff. 

While  uterine  hemorrhage  is  not  a  disease,  but  a  symptom,  it  arises 
from  so  many  different  causes,  and  hence  requires  for  its  cure  so  many 
different  methods  of  treatment,  that  a  volume  like  this  devoted  to  its 
treatment  is  not  inappropriate.  And  probably  in  these  days,  when  so 
much  attention  is  given  to  tubal  diseases,  and  such  brilliant  successes 
are  achieved  in  their  diagnosis  and  operative  treatment,  it  is  well  that 
the  attention  of  the  gynecologist  should  be  directed  to  disorders  much 
more  frequently  met  in  practice.  Quite  recently  it  was  our  duty  to 
examine  a  young  medical  graduate,  and  to  the  question  as  to  the  differ- 
ence between  menorrhagia  and  metrorrhagia  he  could  give  no  reply, 
and  offered  definition  of  neither;  on  the  other  hand,  when  the  examina- 
tion was  turned  to  the  tubes  he  proved  omniscient  of  all  salpingian 
compounds  and  derivatives ;  in  the  new  knowledge  he  had  neglected  the 
older  and  the  more  important. 

This  incident  confirms  us  in  the  view  that  in  such  a  volume  as  the  one 
before  us  we  may  meet  an  actual  want,  and  we  enter  upon  its  examina- 
tion with  increased  interest. 

Between  thirty  and  forty  of  the  first  pages  are  given  to  the  general 
method  of  diagnosis  of  diseases  of  women,  but  this  subject  need  not 
detain  us.    The  following  part  is  occupied  with  the  etiology  of  uterine 


494 


REVIEWS. 


hem orrh ages.  The  author  divides  these  causes  into  organic  and  reflex, 
the  latter  being  occasional,  or  predisposing;  the  chief  of  the  former  are, 
first,  malignant  degenerations,  then  benign,  and  following  these  are 
chronic  phlegmasias  of  the  uterus,  abortion,  pregnancy,  and  puerperal 
diseases,  uterine  displacements,  ovarian  apoplexies,  hemorrhages  of  the 
pelvic  peritoneum,  and  disturbances  of  general  nutrition,  from  obesity, 
blood  stasis,  abdominal  plethora,  and  finally,  traumatic  causes. 

A  table,  prepared  by  the  author,  shows  the  relative  frequency  of  hem- 
orrhages from  several  of  these  causes.  Thus  3  per  cent  of  uterine 
hemorrhages  result  from  endometritis,  25  per  cent,  from  cancer,  and 
19  per  cent,  from  fibromyomata.  A  second  table  shows  the  ages  of 
those  suffering  from  uterine  hemorrhages  resulting  from  different  causes. 
In  illustration,  58  per  cent,  of  women  suffering  from  metrorrhagia,  who 
have  passed  forty-five  years,  have  as  its  cause  cancer,  and  25  per  cent, 
fibromyomata. 

Cancer  of  the  neck  of  the  uterus  is  next  considered.  In  presenting 
the  symptoms  the  author  directs  attention  more  prominently,  we  believe, 
than  any  one  else  has  to  pruritus,  which,  in  some  cases,  he  states, 
becomes  so  severe  as  to  render  life  unendurable  ;  he  attributes  the  dis- 
order to  gastro-intestinal  complications,  and  has  found  that  therapeutic 
means  addressed  to  them  have  been  the  most  successful  in  relieving  the 
pruritus.  In  connection  with  this  topic  he  also  states  that  some  patients, 
suffering  with  cancer,  are  tormented  with  pruriginous  sensations  abruptly 
appearing  upon  different  parts  of  the  body,  and  suddenly  disappearing. 
These  patients  are  especially  liable  to  a  rapid  recurrence  of  cancer  after 
extirpation. 

Sneguireff  has  found  in  90  per  cent,  of  cases  a  characteristic  white 
coloration  of  the  vaginal  entrance,  and  that  independently  of  cancer  of 
the  uterus  this  peculiar  white  appearance  is  never  presented  except  in 
women  from  sixty  to  seventy  years  of  age,  who  are  entirely  free  from 
diseases  of  the  uterus  or  of  its  appendages.  It  is  observed  especially  at 
the  anterior  extremity  of  the  vagina,  where  there  will  be  found  at  the 
level  of  the  inferior  border  of  the  meatus  two  white  bands  directed 
along  the  sides,  and  they  may  extend  so  as  to  meet  below  at  the  level  of 
the  fourchette.  He  considers  this  white  color-line  as  much  more  charac- 
teristic of  cancer  than  the  bluish  hue  of  the  vulva,  first  described  by 
Jacquemin,  is  of  pregnancy;  this  sign  certainly  demands  the  attention 
of  observers. 

In  considering  the  subject  of  medicines  employed  in  cases  of  uterine 
cancer  the  author  gives  a  caution  in  regard  to  the  use  of  chloroform,  or 
of  medicines  acting  upon  the  heart,  lest  this  organ  has  undergone  fatty 
changes  ;  he  mentions,  in  confirmation  of  this  caution,  instances  in  which 
the  administration  of  ergot,  used  for  the  purpose  of  arresting  hemor- 
rhage, was  followed  by  severe  dyspnoea  and  cyanosis  ;  the  same  effect, 
though  in  a  less  degree,  was  observed  after  the  use  of  digitalis. 

Sneguireff,  in  considering  the  radical  cure  of  cancer  of  the  neck  of 
the  uterus,  states  that  in  no  form  of  the  disease,  whatever  operation, 
slight  or  grave,  be  performed,  in  good  or  in  bad  conditions,  can  we  be 
certain  there  will  be  no  recurrence.  "  If,  then,  asked  as  to  this,  a  vague 
response  should  be  given;  that  will  be  very  much  better  than  to  flatter 
the  friends  of  the  patient  by  deceitful  assurances  which  can  only  dis- 
credit surgery  and  the  surgeon." 

Cancer  and  sarcoma  of  the  body  and  of  the  fundus  of  the  uterus  are- 


SNEGUIREFF,  UTERINE  HEMORRHAGES. 


495 


next  presented,  but  the  subject  is  very  meagrely  considered,  and  we  find 
no  points  of  special  importance. 

We  are  somewhat  surprised  to  find  that  the  author  asserts,  in  the  dis- 
cussion of  fibromyomata,  that  these  tumors  may  be  congenital,  for  in  the 
works  of  gynecologists  in  general  there  will  not  be  found  any  confirma- 
tion of  this ;  indeed,  the  youngest  subject  in  which  such  a  growth  has 
been  found  was  ten  years  old,  the  case  of  Seigel. 

The  author  makes  the  following  statement  as  to  the  progress  of  cancer, 
in  case  this  should  be  one  of  the  complications  of  uterine  fibroids — he 
has  met  with  seven  examples  of  such  complication — that  this  is  especi- 
ally characterized  by  its  slowness,  and  the  little  tendency  to  invasion  of 
adjacent  tissues. 

The  following  chapter  discusses  chronic  metritis,  endometritis,  and 
lacerations  of  the  neck  of  the  uterus  as  causes  of  uterine  hemorrhage, 
aud  then  the  subject  of  abortion  is  considered ;  but  nothing  worthy  of 
special  remark  is  here  presented. 

It  is  not  necessary  to  continue  an  account  of  the  causes  of  uterine 
hemorrhage,  as  presented  by  the  author,  and  after  a  brief  reference  to 
the  subject  of  congenital  anteflexion  of  the  neck  and  conical  neck,  we 
will  pass  to  that  of  the  treatment.,  Sneguireff  states  that  anteflexion  is 
the  most  frequent  of  developmental  anomalies  of  the  uterus.  "  Of  7599 
patients,  the  number  of  anomalies  of  development  was  790 — that  is,  10.40 
per  cent.  Of  the  790,  245,  or  31.0  per  cent.,  were  treated  for  anteflexions. 
Add  to  these  the  cases  of  conical  neck,  139,  and  of  anteflexion  with 
conical  neck,  the  proportion  is  59.11  per  cent.,  so  that  more  than  one-half 
of  the  total  number  of  congenital  vices  of  conformation  belong  to  ante- 
flexion and  conical  neck."  He  further  states  "  that  of  the  different  classes 
of  society  the  middle  educated  class  is  more  predisposed  to  this  anomaly 
of  development."  He  adds  that  much  the  largest  contingent  of  patients 
who,  in  consequence  of  sterility  resulting  from  anteflexion,  come  to  con- 
sult the  physician,  is  furnished  by  the  Israelites.  "  The  reason  for  this 
fact,  apparently,  is  that  in  Russian  families  sterility  is  regarded  neither 
as  a  dishonor  nor  a  cause  for  divorce,  while,  for  the  married  Israelites, 
a  sterility  of  nine  years  may  involve  divorce ;  these  women  most  fre- 
quently come  after  seven  or  eight  years  of  marriage,  seeking  cure  for 
their  sterile  condition." 

Under  the  head  of  treatment,  the  author  first  considers  that  of  metror- 
rhagia in  general,  and  then  of  the  different  varieties  in  reference  to 
their  causation.  Nevertheless,  all  hemorrhages  from  the  womb  do  not 
require  treatment,  for  their  arrest  may  be  followed  by  serious  conse- 
quences, and  still  others  may  require  very  cautious  cure.  Thus,  among 
beneficial  metrorrhagias  may  be  mentioned  those  observed  at  the  meno- 
pause in  obese,  plethoric  women,  attacked  by  an  affection  of  the  heart, 
or  of  the  liver,  or  suffering  with  atheroma ;  so,  too,  in  some  diseases  of 
the  uterus,  in  ovaritis,  and  in  ovarian  neuralgia,  a  moderate  hemorrhage 
makes,  as  it  were,  part  of  the  treatment.  Moreover,  if  the  tubes  are 
involved,  and  liquid  accumulated  in  them,  a  condition  not  unseldoin 
present  in  chronic  metritis,  should  contractions  of  the  tubes  be  excited 
this  fluid  may  be  forced  into  the  peritoneal  cavity,  resulting  in  a  limited 
or  in  a  general  peritonitis;  but  as  almost  all  the  agents  used  as  uterine 
haemostatics  cause  contractions  of  the  uterus  and  of  the  appendages,  the 
accident  mentioned  may  result  from  their  use.  Great  prudence  must  be 
used  in  arresting  a  metrorrhagia  which  alternates  with  haemoptysis,  or 


496 


REVIEWS. 


one  occurring  in  nervous  persons  with  hereditary  predisposition  to 
organic  diseases  of  the  central  nervous  system. 

Among  medicines  ergot  is  first  considered,  the  form  recommended  the 
infusion,  and  the  cases  to  which  it  is  thought  especially  applicable  those 
of  hemorrhage  following  labor  or  miscarriage — in  general,  whenever  the 
uterus  is  increased  in  size  and  its  tissues  softened.  The  remedy  has 
little  effect  if  the  uterus  is  hard  and  fibrous,  and  if  then  used  is  to  be 
employed  in  small  doses,  or  hypodermatically.  If  the  hemorrhage  has 
caused  great  anaemia,  ergot  gives  but  feeble  results ;  it  must  be  adminis- 
tered cautiously  if  the  woman  is  nursing,  lest  the  secretion  of  milk 
lessen  or  disappear.  The  perchloride  of  iron  is  advised  in  three-drop 
doses,  three  or  four  times  a  day,  for  those  patients  who  have  suffered  a 
long  time  from  menorrhagia  or  metrorrhagia.  Digitalis  in  the  form  of 
infusion,  is  indicated  in  hemorrhage  resulting  from  blood  stasis  in  the 
abdomen  or  pelvis,  and  also  in  cardiac  affections.  The  tincture  of 
Indian  hemp  is  valuable  only  when  recently  prepared.  It  responds  to 
the  following  indications  :  It  calms  pelvic  pain  involving  the  uterus  and 
its  appendages,  the  bladder  and  the  rectum,  lessens  the  uterine  flow,  and 
produces  sleep ;  it  is  useful  to  relieve  the  suffering  from  chronic  metritis, 
acute  perimetritis,  and  parametritis,  in  dysmenorrhea,  in  vesical  irrita- 
bility, in  dysuria,  and  in  painful  defecation  when  the  suffering  arises 
from  the  uterus  ;  second,  during  pregnancy  this  agent  acts  very  favor- 
ably upon  the  painful  contractions  and  hemorrhages  ;  third,  it  is  useful 
in  the  insomnia  accompanying  uterine  diseases. 

Among  other  uterine  haemostatics  recommended  are  the  acid  of  Haller, 
five  to  ten  drops,  three  or  four  times  a  day,  and  phosphoric  acid  in  an 
unstrained  decoction  of  cinnamon ;  the  former  is  recommended  in  the 
metrorrhagia  of  pregnancy,  or  of  beginning  abortion,  and  the  latter  in 
hemorrhages  depending  upon  the  disease  of  Werlhof  and  those  of 
scorbutus. 

Next  follows  hydrotherapy  in  its  various  applications,  very  great 
prominence  being  justly  given  to  vaginal  injections  of  hot  water.  In 
regard  to  position  when  the  injections  are  administered,  he  rejects  the 
sitting,  or  half  sitting,  or  erect,  and  insists  that,  as  a  rule,  the  patient 
should  be  recumbent :  only  in  exceptional  cases  where  the  prompt  arrest 
of  an  obstinate  hemorrhage  is  desired  is  she  to  take  the  genu-pectoral 
position.  In  considering  the  effect  of  hot  water  upon  the  uterus  he  gives 
the  following  results  :  Lessened  volume  of  the  organ,  the  diminution  being 
so  much  more  marked  as  the  consistence  of  the  uterus  is  less ;  diminution 
of  pain ;  lessened  secretion  from  the  uterus — though  at  first  it  may  be  in- 
creased, it  soon  diminishes  and  may  entirely  disappear ;  in  addition  to 
the  effect  of  hot-water  injections  upon  the  quantity  of  the  secretion,  the 
quality  changes,  and  thus  a  leucorrhoea  may  lose  its  fetid  character. 
Beside  these  results  hot-water  injections  furnish  the  most  powerful  anti- 
phlogistic means  in  gynecology.  Hot- water  injections,  especially  under 
the  form  of  continuous  irrigation,  have  a  decided  sleep-producing  power  ; 
some  patients  go  to  sleep  during  the  injection,  and  others  after  it ;  the 
sleep  is  brief,  usually  unattended  by  dreams,  and  is  refreshing.  In  some 
cases,  however,  which  are  quite  rare,  hot  injections  cause  sleeplessness, 
hallucinations,  or  even  syncope,  and  then,  of  course,  they  should  be 
abandoned.  Among  other  unpleasant  symptoms  that  may  result  are 
acceleration  of  the  pulse,  which  may  become  irregular,  palpitation  of 
the  heart,  cardiac  distress,  hurried  respiration,  which  may  even  present 


SNEGUIREFF,  UTERINE  HEMORRHAGES. 


497 


some  asthmatic  characters.  Vertigo,  dimness  of  vision,  and  ringing  in 
the  ears  may  also  occur,  and  when  these  are  observed,  of  course,  the  in- 
jections must  be  at  once  discontinued.  We  know  .no  writer  who  has 
entered  so  fully  into  the  subject  of  hot-water  vaginal  injections,  and  we 
regard  this  portion  of  his  work  as  of  the  greatest  value  ;  he,  of  course, 
acknowledges  indebtedness  to  Emmet  for  this  means  of  treating  diseases 
of  women. 

The  subject  of  continuous  irrigation  in  puerperal  fever  is  presented 
with  considerable  fulness,  the  writer  having  collected  more  than  fifty 
cases  in  which  this  treatment  was  employed,  but  the  propriety  of  intro- 
ducing this  subject  in  a  work  devoted  to  uterine  hemorrhages  is  at  least 
doubtful. 

Cold  injections,  both  intermittent  and  continuous,  are  considered,  but 
since  the  author  states  he  has  abandoned  them  as  haemostatic  means,  no 
further  reference  need  be  made  to  the  topic.  He  regards  the  use  of  ice 
in  the  vagina  in  the  slighter  forms  of  hemorrhage  as  useful ;  and  so  too, 
an  ice  bladder  may  be  applied  to  the  abdomen  in  conjunction  with  hot- 
water  injections  in  the  vagina:  he  gives  a  just  caution  in  reference  to 
the  external  use  of  ice,  stating  that  in  very  ansemic  and  fleshy  women 
the  prolonged  application  of  bladders  of  ice  ought  to  be  carefully 
watched,  for  frequently  in  fact  superficial  eschars  are  observed,  especially 
if  the  patients  have  previously  had  irritant  ointments  applied,  or  con- 
tinued application  of  hot  compresses. 

Revulsion  to  the  surface  by  means  of  hot-water  bags,  et  cetera,  is  briefly 
presented,  as  well  as  the  similarly  produced  ischsemia  of  the  internal 
organs  by  means  of  a  hot  bath.  The  value  of  special  treatment  by 
hydrotherapy  is  presented.  He  regards  this  treatment  as  useful  in  the 
hemorrhage  due  to  obesity,  in  that  which  is  associated  with  abdominal 
plethora  in  connection  with  intestinal  atony  and  obstinate  constipation, 
the  uterus.not  having  undergone  malignant  degeneration  ;  in  uterine  dis- 
placements, especially  retroflexion  or  retroposition  with  or  without  in- 
flammation or  tumors  of  the  ovary ;  in  subperitoneal  or  interstitial 
fibromata ;  in  the  hemorrhages  of  the  menopause,  and  in  those  of  chronic 
metritis.  He  warns  against  the  danger  from  the  application  of  cold 
water  in  the  case  of  a  patient  who  has  previously  had  peritonitis,  of  a 
return  of  the  disease,  and  also  states  the  discouraging  fact  that  in  some 
cases  the  cure  by  hydrotherapic  treatment  is  not  permanent,  and  must 
be  resumed  a  second  or  even  a  third  year. 

Intrauterine  injections  are  briefly  referred  to.  The  author  advises 
for  these  Braun's  syringe,  and  regards  tincture  of  iodine,  one  part  to  four 
of  glycerine,  or  else  the  undiluted  tincture,  the  best  material  for  inject- 
ing ;  such  a  preparation  as  either  would  be  a  very  feeble  haemostatic 
indeed,  and  probably  the  alcohol  is  really  the  most  important  agent,  the 
quantity  of  iodine  being  so  small.  After  giving  the  precautions  neces- 
sary in  case  of  haemostatic  uterine  injections,  he  states  that  even  with 
the  utmost  care  the  latter  are  not  exempt  from  danger,  and  that  they 
ought  to  be  rarely  employed. 

Mechanical  means,  including  the  vaginal  and  the  uterine  tampon  and 
massage,  are  presented,  as  well  as  hygienic  and  dietetic  care  pointed  out. 
Next  follows  a  chapter  devoted  to  sun  baths,  for  the  use  of  which  the 
author  acknowledges  his  indebtedness  to  Emmet.  These  baths  are  pro- 
scribed for  all  patients  who  have  suffered  for  a  long  time  with  affections 
of  the  genital  organs,  and  have  undergone  various  treatments,  chiefly 

NO.  CLXXXVIII.  —  OCTOBER,  1887.  32 


498 


REVIEWS. 


cases  of  chronic  metritis,  chronic  inflammation  of  the  ovaries,  of  the 
peritoneum,  with  intestinal  atony,  dyspepsia,  hysteria.  The  baths  are 
taken  in  the  following  manner:  The  patient  has  the  abdomen  and  lower 
limbs  covered  with  black  clothing,  the  chest  and  head  with  white ;  she 
lies  extended  upon  a  bed  or  couch  in  the  full  sun,  an  umbrella  protect- 
ing the  upper  part  of  the  body,  while  the  abdomen  and  lower  limbs  are 
uncovered.  For  the  first  half  hour  she  remains  upon  her  back,  and 
then  turns  upon  her  side,  or  upon  her  abdomen  ;  the  bath  lasts  from  one 
to  two  hours.   In  some  cases  twenty,  in  others  sixty  baths  are  employed. 

The  final  portion  of  the  volume  is  occupied  with  the  treatment  of  the 
different  affections  causing  metrorrhagia.  Here  we  have  presented  the 
medical  and  surgical  means  used  in  malignant  and  in  benign  uterine 
growths,  including  abdominal  and  vaginal  extirpation  of  the  uterus,  the 
treatment  of  endocervicitis  and  of  endometritis,  of  bilateral  laceration 
of  the  cervix  by  Emmet's  method,  of  chronic  metritis,  of  hemorrhage 
from  abortion  and  during  pregnancy,  of  the  various  positional  disorders 
of  the  uterus,  and  other  affections  resulting  in  metrorrhagia.  But  hav- 
ing already  occupied  so  much  space  with  this  notice,  there  is  hardly 
room  left  to  consider  these  several  topics. 

We  have  endeavored  to  present  a  fair  analysis  of  this  volume,  and 
we  think  our  readers  will  agree  with  us  in  concluding  that  the  author 
has  prepared  a  work  which  will  prove  quite  useful  to  the  profession. 

T.  P. 


Dermatitis  Venenata:  An  Account  of  the  Action  of  External 
Irritants  upon  the  Skin.  By  James  C.  White,  M.D.,  Professor  of 
Dermatology,  Harvard  University.    Pp.  203.    Boston  :  1887.  . 

The  author  of  the  book  before  us  is  a  botanist  as  well  as  a  distin- 
guished dermatologist,  and  is,  therefore,  eminently  qualified  to  deal  with 
the  subject  in  hand  in  its  several  aspects.  We  may  state  that  the  subject- 
matter  has  been  prepared  from  a  practical  standpoint,  supported  by 
scientific  methods  of  observation.  It  is  an  admirable  essay,  original  and 
broad  in  its  scope,  and  constitutes  a  valuable  contribution  to  dermatology. 

Under  the  title  dermatitis  venenata  are  included  all  those  forms  of 
inflammation  of  the  skin  which  are  produced  by  the  direct  action  of  irri- 
tating agencies  externally  applied,  belonging  to  the  vegetable,  animal, 
and  mineral  worlds,  and  to  other  classes  of  matter  more  difficult  of  defi- 
nition. Most  frequently  the  inflammation  is  due  to  plants  possessing 
irritating  properties,  but  numerous  other  irritant  substances,  such,  for 
example,  as  chemicals,  dyes,  and  certain  insects,  also  not  infrequently 
act  injuriously  upon  the  integument.  The  effect  produced  upon  the  skin 
in  all  cases  is  an  inflammation,  varying  greatly  in  degree  and  intensity, 
from  a  mild  erythema  to  a  severe  and  deep-seated  disturbance.  All 
grades  and  forms  of  the  inflammatory  process  are  met  with.  Erythema 
may  appear  as  a  defined  lesion,  a  macule,  or  as  a  patch,  and  is  usually 
accompanied  with  oedema,  which  is  often  marked,  as,  for  example,  in 
dermatitis  from  rhus.  Tho  wheal,  papule,  vesicle,  bleb,  and  pustule,  as 
well  as  the  scale,  crust,  excoriation,  ulcer,  and  scar,  may  all  be  modes  of 
pathological  expression. 


WHITE,   DEKMATITIS  VENENATA. 


499 


The  description  given  by  the  author  of  the  intimate  cutaneous  changes 
that  take  place  in  these  several  forms  of  inflammation  is  original,  and  is 
presented  with  a  masterly  hand.  In  some  cases  the  diagnosis  of  derma- 
titis venenata  must  rest  alone  with  the  history  or  etiology,  the  signs  of 
inflammation  being  similar,  if  not  identical,  with  other  forms  of  disease 
arising  from  internal  causes.  Especially  is  this  true  where  the  subject 
attacked  is  eczematous — that  is,  is  prone,  from  one  cause  or  another,  to 
outbreaks  of  eczema,  of  which  instances  in  practice  are,  as  is  well  known, 
sufficiently  numerous. 

The  author  first  takes  up  dermatitis  produced  by  plants,  of  which 
there  are  many  capable  of  causing  more  or  less  cutaneous  inflammatory 
disturbance.  The  list  is  by  no  means  small,  sixty  being  mentioned,  which 
are  either  native  or  have  been  introduced  into  the  United  States.  Of 
these  we  may  distinguish  those  which  are  capable  of  producing  injurious 
effects  while  growing,  either  by  direct  contact  or  near  approach ;  those 
which  act  only  when  some  part  is  purposely  applied  to  the  skin ;  and, 
thirdly,  those  which  are  active  only  in  a  concentrated  form  or  through 
some  principle  artificially  extracted  from  them.  Some  of  these  act  by 
mechanical  irritation,  as,  for  example,  the  hairs  of  mucuna ;  some  by 
special  poison  glands,  as  the  stinging  glands  of  the  urticse ;  some  by 
emanations,  as  the  volatile  principle  in  rhus ;  others  by  contact  with  the 
acid  or  poisonous  elements  contained  in  the  plants.  Among  the  most 
poisonous,  and  those  producing  by  far  the  most  mischief  on  the  skin, 
stand  the  anacardiacese,  or  rhus  family,  of  which  three  species  grow 
abundantly  in  the  United  States,  namely,  rhus  toxicodendron,  or  poison 
ivy  ;  rhus  venenata,  or  poison  sumach  ;  and  rhus  diversiloba,  or  poison 
oak.  Rhus  toxicodendron,  called  by  earlier  botanists  r.  radicans,  is  also 
popularly  known  as  poison  vine,  poison  oak,  and  mercury.  The  second 
species,  rhus  venenata,  the  r.  vernix  of  Linnaeus,  is  also  known  as  poison 
dogwood,  poison  elder,  poison  ash,  and  is  a  tree  growing  mostly  in 
swampy  places,  reaching  the  height  of  about  twenty  feet.  Rhus  diver- 
siloba is  the  common  poison  oak  of  the  Pacific  coast,  and  closely  resem- 
bles rhus  toxicodendron. 

Dr.  White  gives  a  full  and  interesting  account  of  these  plants,  direct- 
ing special  attention  to  points  whereby  they  may  be  at  all  times  readily 
distinguished,  together  with  a  complete  description  of  the  eruption,  its 
peculiarities,  and  its  treatment.  While  the  numerous  remedies  which 
have  been  found  to  be  more  or  less  useful  in  the  local  treatment  of  this 
inflammation  are  briefly  mentioned  by  the  author,  the  excellent  results 
to  be  derived  from  some  of  them  are,  we  think,  not  referred  to  suffi- 
ciently. Thus,  the  great  value  of  grindelia  robusta,  especially  in  the 
form  of  a  fluid  extract,  largely  diluted,  is  not  specially  mentioned.  It 
is  certainly  one  of  our  best  remedies.  The  author  is  firmly  of  the  opinion 
that  there  are  no  so-called  specifics  for  this  affection,  black-wash,  em- 
ployed either  alone  or  with  some  mild  ointment  or  powder,  as  in  vesicular 
eczema,  being  regarded  for  the  majority  of  cases  as  by  far  the  best  appli- 
cation. In  dispensary  practice  the  following  is  generally  prescribed  : 
zinci  oxidi,  ^iv  ;  acidi  carbolici,  31 ;  aq.  calcis,  Oj. 

The  other  plants,  of  importance,  are  arnica  (used  in  the  form  of  a 
tincture  as  a  domestic  remedy  for  bruises  and  sprains),  which  is  capable 
of  giving  rise  to  a  virulent  dermatitis;  white-weed,  or  ox-eye  daisy; 
croton  oil ;  goa  powder ;  cowhage  ;  and  nettle.  Next  in  order  may  In- 
noted  a  list  of  other  irritants,  some  organic,  others  inorganic,  which 


500 


REVIEWS. 


occasionally  work  mischief  on  the  skin,  many  of  which,  such  as  arsenic, 
mercury,  sulphur,  tar,  carbolic  and  salicylic  acids,  are,  when  properly 
employed,  most  useful  remedies.  Finally,  irritants  belonging  to  the 
animal  kingdom,  such  as  the  mosquito,  gnat,  bed-bug,  flea,  itch  insect, 
louse,  spider,  and  caterpillar,  receive  brief  consideration  from  the 
author. 

Thus,  it  will  be  seen  that  Dr.  White  has  opened  a  new  field  in  derma- 
tology, and  has  collected  and  brought  together  much  practical  informa- 
tion that  before  only  existed  in  the  form  of  widely  scattered  papers. 
The  work  has  been  well  done,  and  we  take  pleasure  in  commending 
the  volume  to  all  who  are  in  any  way  interested  in  the  subject. 

L.  A.  D. 


Besearches  upon  the  Venom  of  Poisonous  Serpents.  By  S.  Weir 
Mitchell,  M.D.,  Member  of  the  National  Academy  of  Sciences,  U.  S.  A., 
President  of  the  College  of  Physicians  of  Philadelphia,  and  Edward  T. 
Eeichert,  M.D.,  Professor  of  Physiology  in  the  University  of  Pennsyl- 
vania. Folio  pp.  ix.  186.  4  Woodcuts  and  5  Plates.  Washington  City : 
Published  by  the  Smithsonian  Institution,  1886. 

An  admirable  piece  of  work  which  has  even  already  won  for  itself  a 
portion  of  the  recognition  its  merits  deserve,  but  which  will  be  the 
starting-point  for  any  more  exhaustive  investigation  of  the  same  nature 
in  the  future.  A  plain  statement  of  facts  observed  such  as  is  found  in 
these  pages  is  worth  volumes  of  conjecture  without  experimental  evi- 
dence to  back  it,  and  for  that  reason  the  work  here  recorded  must 
always  be  of  value  and  can  never  be  neglected  in  future  research  upon 
this  important  subject — more  important,  of  course,  in  parts  of  the 
world  infested  by  venomous  reptiles  to  a  greater  degree  than  are  the 
Middle  States  of  North  America,  but  necessary  even  there  for  the  pos- 
sible results  in  rescuing  life  from  the  grasp  of  such  deadly  enemies. 

The  fact  of  the  rarity  of  venomous  reptiles  in  the  region  where  this 
investigation  was  conducted  limited  its  authors  in  a  very  serious  way, 
because  a  large  supply  of  snake  venom  was  out  of  the  question  at  any 
one  time,  so  that  their  experiments  were,  to  a  certain  extent,  limited  in 
time  and  variety.  They  have  themselves,  however,  recognized  these 
limitations,  and  with  the  modesty  of  the  true  scientific  spirit  claim 
nothing  for  their  conclusions  w7hich  is  not  fully  justified  by  the  premises 
upon  which  they  are  based.  The  work  is,  in  some  sort,  a  continuation 
of  what  was  begun  by  Dr.  Mitchell  as  long  ago  as  1858,  and  the  spirit 
in  which  this  report  is  written  is  well  expressed  by  the  authors  in  the 
sentence :  "  We  have  foreborne  to  overload  this  paper  with  comments  on 
the  later  researches  of  others,  and  have  made  the  discussion  of  our  own 
work  as  brief  as  was  consistent  with  clearness." 

The  work  is  divided  into  eleven  chapters,  and  begins,  as  is  most 
natural  with  a  consideration  of  the  "  Physical  Characteristics  of  Venom," 
which  are  fluids  varying  in  color  from  a  very  pale  amber  to  a  deep 
yellow.  Dried  with  moderate  rapidity  they  become  beautiful  cracked 
masses  closely  resembling  ^a  mass  of  crystals,  which  are  yellow,  very 


MITCHELL,   EEICHERT,   SNAKE-VENOM.  501 


fragile  and  translucent,  and  retain  their  poisonous  properties  for  years. 
Under  the  microscope,  especially  in  vigorous  reptiles,  the  venom  shows  a 
number  of  floating  granular  bodies  which  seem  to  increase  in  number 
as  the  vigor  of  the  reptile  decreases  ;  besides  these  bodies  are  also  found 
a  few  leucocytes  and  epithelial  cells,  and  always  micrococci,  together 
wTith  other  forms  of  bacteria  in  old  specimens. 

The  specific  gravities  of  various  species  of  venom  are  mentioned. 

Following  this  comes  the  consideration  of  the  chemical  aspect  of 
venoms  and  several  extremely  interesting  facts  are  here  revealed.  Fresh 
venom,  allowed  to  stand,  separates  into  a  viscid  fluid  and  a  sediment 
which  contains  the  granular  bodies,  epithelial  cells,  etc.,  and  which, 
after  thorough  washing,  gives  absolutely  no  toxic  reaction  when  injected 
into  animals.  The  toxic  properties  of  venom  are,  therefore,  to  be  looked 
for  in  the  portion  remaining  after  the  removal  of  this  "  insoluble  pre- 
cipitate." If  this  residue  be  placed  in  a  dialyzer  after  mixing  with 
water,  a  whitish  precipitate  will  be  thrown  down  in  the  dialyzer  in 
abundance  if  the  process  be  continued  long  enough.  This  precipitate, 
thoroughly  washed,  gives  reactions  peculiar  to  the  globulins,  and  the 
filtrate  obtained  in  the  dialyzer  is  shown  by  proper  tests  to  contain 
readily  dialyzable  substances  which  belong  among  the  peptones.  The 
authors,  therefore,  show  that  venom  contains  in  varying  proportions  for 
different  species  of  reptiles,  specimens  of  two  classes  of  proteid  bodies — 
the  one  belonging  among  the  globulins,  the  other  among  the  peptones. 
The  venom-globulin  they  found  to  be  of  a  complex  nature  and  capable 
of  being  resolved  into  three  principles,  each  a  globulin,  by  processes 
which  they  have  given  as  names  to  the  result — i.  e.,  water- venom- 
globulin,  copper-venom-globulin,  and  dialysis-venom-globulin.  Each  of 
these  three  substances  was  subjected  to  careful  tests  as  to  its  behavior 
toward  chemical  reagents  and  its  identity  fully  established.  This  was 
also  done  in  the  case  of  venom-peptone,  and  both  principles  were  ex- 
amined from  the  Crotalus  adamanteus,  the  Ancistrodonpiscivorus,  and  the 
Cobra.  In  the  case  of  the  first  the  dried  venom  was  found  to  contain 
24.6  per  cent  of  globulins,  of  the  second  7.8  per  cent.,  and  of  the  third 
1.75  per  cent.,  and  necessarily  these  varying  proportions  of  the  globulins 
and  peptones  in  different  venoms  are  of  great  importance  in  explaining 
the  varying  physiological  peculiarities  resulting  from  poisoning  by 
different  species  of  snakes. 

The  authors  next  take  up  the  question  of  the  "  Effects  of  Various 
Agents  on  Venom,"  and  employed  moist  and  dry  heat  for  varying  periods 
of  time  and  in  varying  degrees  of  intensity  upon  the  venoms  of  different 
serpents.  Dry  heat  acting  upon  dry  venom  at  230°  F.  for  thirty 
minutes  did  not  destroy  its  activity,  but  moist  heat  at  212°  F.  for  two 
minutes  took  away  all  of  its  active  power  in  Crotalus  adamantheus 
venom,  and  was  even  more  marked  in  its  effects  upon  the  venom  of  the 
moccasin  and  cobra.  A  number  of  chemical  substances  were  used  as 
tests  with  varying  results  upon  different  venoms. 

Various  methods  of  nitration  were  adopted  with  a  certain  amount  of 
success,  but  snake-bile,  the  popular  remedy  for  a  snake-bite,  was  tried 
and  found  to  have  absolutely  no  effect  in  diminishing  the  toxic  action 
of  the  venom  with  which  it  was  injected. 

Their  experiments  show  very  conclusively  that  as  a  local  antidote,  per- 
manganate of  potash  is  the  best  for  all  snake  poisons,  and  that  ferric 
chloride  is  a  very  efficient  destroyer  of  the  venom  of  our  own  snakes, 


502 


REVIEWS. 


which  owe  their  vigor  to  venom  globulin,  but  has  little  value  as  a  local 
antidote  to  the  peptone,  which  gives  power  to  the  poison  of  the  cobra, 
and  in  any  case  its  use  is  indicated  locally  in  large,  full  doses.  Bromine 
may  prove  efficacious  as  well  as  the  strong  alkalies. 

The  effects  of  venom  when  applied  to  various  mucus  and  serous  sur- 
faces was  next  studied,  showing  that  it  might  be  absorbed  with  varying 
rapidity  from  such  situations,  and  then  the  action  of  venom  upon  the 
nervous  system  was  taken  up.  In  the  latter  case  all  the  observations 
tended  to  show  that  the  respiratory  centre  is  the  most  vulnerable 
point  of  the  nervous  system,  that  the  coordinating  and  volitional  centres 
are  those  markedly  affected,  that  the  sensory  part  of  the  spinal  cord  and 
the  sensory  nerves  are  next  attacked,  and  finally,  that  the  motor  parts 
of  the  cord  and  the  motor  nerves  are  the  last  to  succumb. 

A  comparison  of  the  local  effects  of  the  globulins  and  peptones  shows 
a  marked  difference  between  the  two — in  the  former  case  there  are  local 
bleedings,  fluid  blood,  and  capillaries  giving  way  soon  after  the  poison 
reaches  them — whilst  peptone  venom  produces  swift  putrefactive  changes, 
and  shows  but  slight  capacity  to  make  fluid  the  blood  or  to  corrode  the 
capillaries. 

A  long  series  of  experiments  to  discover  the  effect  of  venoms  and  their 
globulins  and  peptones  upon  the  pulse-rate,  was  made.  By  this  it  was 
found  that  of  the  globulins,  the  water- venom-globulin  is  the  most  potent, 
the  copper-venom-globulin  the  least  so,  whilst  the  results  obtained  with 
venom-peptones  agree  with  those  obtained  with  pure  venom,  producing 
a  primary  increase  and  a  secondary  diminution  of  the  pulse-rate — the 
first  effect  by  excitation  of  the  accelerator  centres  in  the  medulla,  and 
that  the  impulses  are  carried  through  fibres  passing  chiefly  by  the  spinal 
cord. 

The  action  of  venoms  and  their  isolated  globulins  and  peptones  upon 
the  arterial  pressure,  wTas  the  next  point  investigated.  The  injection  of 
pure  venom  subcutaneously  producing  a  progressive  fall  of  blood  press- 
ure, whilst  intravenously  the  fall  is  sudden  and  marked,  and  may  be 
immediately  followed  by  death ;  whilst  the  results  of  the  experiments 
upon  globulins  and  peptones  seemed  to  justify  the  conclusions  that  the 
isolated  principles  exert  the  poisonous  actions  of  pure  venoms  on  the 
blood  pressure,  and  that  their  toxic  effects  are  simply  different  in  degree. 

Naturally,  the  next  thing  to  investigate  was  the  effect  of  these  venoms 
and  the  venom-globulins  and  venom-peptones  upon  the  respiration,  the 
results  of  the  experiments  upon  this  point  being  best  given  in  the  words 
of  the  authors,  that  "the  primary  action  of  all  the  above  poisons,  except- 
ing the  copper- venom-globulin,  is  to  cause  an  increase  in  the  number  of 
respirations,  and,  secondarily,  to  diminish  the  respirations  below  the 
normal.  Of  the  different  principles,  the  peptone  seems  to  exert  the  most 
decided  power  in  causing  the  accleration,  while  the  copper-venom-glo- 
bulin seems  utterly  to  lack  this  action. 

The  experimental  evidence  offered  as  regards  the  pathology  of  venom 
is  not  so  satisfactory  as  the  rest  of  the  paper — especially  the  methods 
employed  for  the  isolation  and  cultivation  of  the  bacteria  observed  in 
the  venoms.  The  whole  history  of  the  action  of  venoms  argues  against 
the  fact  that  their  activity  is  due  to  the  propagation  of  bacteria  in  the 
parts  affected  by  the  poison.  Nothing,  however,  prevents  the  supposi- 
tion that  these  poisons  may  be  the  results  of  the  previous  growth  of  bac- 
teria in  the  mouths  or  venom-sacs  of  the  serpents  themselves — a  point  of 


CHARCOT,  DISEASES  OF   THE   NERVOUS  SYSTEM 


503 


extreme  importance,  and  one  which  these  experiments  have  done  nothing 
to  elucidate.  This  is  the  more  to  be  regretted  because  it  was  an  oppor- 
tunity not  likely  to  occur  soon  again. 

The  effects  of  the  various  venoms  upon  the  tissues  of  the  body — both 
macroscopically  and  microscopically — are  well  pointed  out,  and  are  well 
explained  by  the  facts  observed  in  the  first  portion  of  the  treatise.  A 
summary  of  the  conclusions  reached  closes  the  text,  and  a  fine  bibliog- 
raphy of  the  literature  of  the  subject  fitly  ends  one  of  the  most  credit- 
able scientific  productions  of  recent  years.  An  index  and  several  fine 
plates  leave  nothing  to  be  desired.  H.  C.  E. 


Lecons  suit  les  Maladies  du  Systeme  Nerveux  faites  a  la  Sal- 
petriere.  Par  J.  M.  Charcot,  Professeur  a  la  Faculte  de  M6decine  de 
Paris,  etc.  Tome  troisieme,  8vo.  pp.  519.  Paris :  A  Delahaye  et  E. 
Lecrosnier,  1887. 

Lectures  on  Diseases  of  the  Nervous  System  delivered  at  the 
Salpetriere  Hospital.    By  Prof.  J.  M.  Charcot.   Vol.  III. 

The  first  two  volumes  of  Charcot's  lectures  are  so  widely  known, 
having  passed  through  three  editions  and  having  been  translated  into 
several  languages,  that  the  third  volume  will  be  heartily  welcomed  by 
his  many  students  and  admirers.  It  contains  twenty-six  clinical  lectures 
upon  various  forms  of  nervous  disease,  delivered  during  the  past  four 
years  at  his  clinique.  The  majority  have  already  appeared  in  the  pages 
of  Le  Progres  Medical,  but  are  well  worth  a  second  perusal. 

The  subjects  discussed  are  muscular  atrophy  subsequent  to  joint  dis- 
ease, contractures  of  traumatic  origin,  tic  convulsif,  migraine  ophthal- 
rnique,  myelitis  following  sciatica,  cervical  pachymeningitis,  aphasia, 
tremor,  the  classification  of  muscular  atrophies,  and  various  forms  of 
hysteria.  The  last  named  subject  has  attracted  so  much  attention  in 
France,  of  late,  that  it  is  not  surprising  that  one-half  of  the  lectures  are 
devoted  to  its  study ;  hysteria  in  males,  hysterical  contractures,  hys- 
terical monoplegias,  hysterical  coxalgia,  hysterical  mutism,  and  the 
treatment  of  hysteria  by  seclusion,  being  fully  discussed.  The  exact 
but  none  the  less  vivid  description  of  cases,  the  exhaustive  discussion  of 
symptoms  with  interesting  comments,  and  points  of  differential  diagnosis, 
and  the  attractive  style  of  the  lectures,  combine  to  make  this  volume  as 
valuable  an  acquisition  to  any  medical  library  as  either  of  its  pre- 
decessors. 

It  is  possible  in  a  short  space,  to  call  attention  to  only  a  few  of  the 
subjects  of  special  interest  which  are  treated.  The  classification  of  mus- 
cular atrophies  has  only  recently  become  possible,  several  new  forms 
having  been  described  since  Charcot's  first  volume,  which  contained  a 
reference  to  the  subject,  was  issued.  He  groups  them  in  two  categories : 
first,  amyotrophies  of  spinal  origin;  secondly,  primary  progressive  amy- 
otrophies. In  the  first  category  are  included  (1)  the  atrophy  of  amy- 
otrophic lateral  sclerosis;  and  (2)  the  progressive  muscular  atrophy  of 
the  Duchenne-Aran  type.    In  the  second  category  are  grouped  0) 


504 


REVIEWS. 


pseudo-hypertrophic  paralysis;  (2)  juvenile  muscular  atrophy  of  Erb; 
(3)  progressive  infantile  muscular  atrophy  of  Duchenne ;  (4)  the 
hereditary  form  of  progressive  atrophy  of  Ley  den;  and  (5)  transitional 
forms  of  atrophy  in  which  the  muscle,  though  weakened,  is  not  appar- 
ently reduced  in  size,  of  which  Charcot  describes  several  cases.  It  seems 
as  though  no  very  sharp  line  could  be  drawn  between  some  of  these 
forms,  as  the  transitional  cases  described  resemble  two  or  more  varieties. 
This  chapter  is  profusely  illustrated,  but  the  plates  are  of  an  inferior 
kind,  though  made  from  photographs,  and  show  less  distinctly  than 
could  be  desired  the  characteristic  features  of  the  various  types. 

Apropos  of  a  case  of  disseminated  sclerosis  tremor  is  discussed.  The 
tremor  of  sclerosis  ceases  during  rest,  and  is  increased  by  voluntary 
motion  or  by  an  effort  to  restrain  it,  and  the  extent  of  the  excursion  of 
the  trembling  hand  may  be  considerable.  In  paralysis  agitans  the 
tremor  continues  constantly,  is  not  affected  by  motion,  may  be  restrained 
for  an  instant,  and  is  a  fine  trembling,  each  finger  moving  individually. 
In  both  these  forms  as  well  as  in  senile  tremor  the  oscillations  are  slow, 
four  or  five  per  second.  In  senile  tremor  oscillations  of  the  head  are 
quite  constantly  seen.  In  hysterical  tremor  the  movement  is  more  rapid, 
but  is  not  as  quick  as  in  the  vibratory  tremor  of  alcoholism,  mercurial 
poisoning,  general  paresis,  or  Basedow's  disease.  In  the  last  of  these  the 
fingers  never  tremble  individually.  Tremor  is  not  to  be  confounded 
with  choreiform  motions  which  are  not  oscillatory  or  vibratory,  but  are 
spasmodic  twitchings. 

The  cases  of  aphasia  described,  merit  careful  study,  being  almost 
unique.  One  is  the  case  of  a  man,  who,  while  retaining  his  power  to 
speak  and  to  write,  had  lost  the  power  to  read  at  sight.  By  the  aid  of 
his  muscular  sense,  however,  he  was  able  to  recognize  the  meaning  of 
printed  language,  for  when  he  traced  the  letters  which  he  saw  he  became 
conscious  of  their  significance.  Another  case  was  one  of  defect  of  visual 
memory :  faces,  objects,  and  scenes  once  well  known,  being  no  longer 
either  voluntarily  recalled  or  recognized  when  seen.  In  both  these  cases 
homonymous  hemianopsia  was  present ;  and  this  symptom  is  ascribed  to 
a  cortical  lesion  by  Charcot,  an  admission  which  implies  that  his  previ- 
ous scheme  of  the  course  of  the  visual  tract,  which  is  unfortunately  still 
reproduced  in  physiological  text-books,  has  been  abandoned. 

It  will  probably  be  a  source  of  disappointment  to  many  readers  to  find 
so  much  space  devoted  to  the  subject  of  hysteria.  But  much  valuable 
information  is  to  be  found  in  these  lectures,  which  to  many  will  be 
wholly  new.  The  liability  of  spiritualistic  seances  to  induce  hysterical 
phenomena  is  illustrated.  The  subject  of  hysteria  in  the  male  is  one 
whose  importance  must  be  admitted.  Cases  of  this  kind  are,  according 
to  Charcot,  by  no  means  rare.  "  Judging  from  my  daily  experience, 
these  cases  are  often  misunderstood  even  by  competent  physicians.  We 
all  admit  that  an  effeminate  young  man  may  present  hysterical  symp- 
toms, especially  after  excitement,  excesses,  or  emotional  strain.  But 
that  a  vigorous  workman,  rough  and  hardy,  as  for  example,  the  stoker 
of  an  engine,  who  has  never  been  excitable,  at  least,  to  all  appearances, 
may  become  as  hysterical  as  a  female  in  consequence  of  the  shock  of  a 
collision  or  accident,  is  a  fact  which  seems  to  surpass  our  powers  of 
imagination,  but  is  not  the  less  true.  .  .  .  What  misleads  us  chiefly, 
is  the  notion  that  hysteria  must  necessarily  present  in  males  the  same 
clinical  pictures  as  in  females.    In  the  male,  in  fact,  the  disease  is  often 


BUENETT,  TREATISE   ON  ASTIGMATISM. 


505 


characterized  by  the  permanence  and  tenacity  of  its  symptoms.  In  the 
female  it  is  its  unstability,  the  constant  change  of  symptoms,  which  is 
considered  typical.  Yet,  even  in  the  female  there  are  symptoms  which 
are  permanent  and  difficult  to  modify  or  to  relieve  by  medical  means ; 
hence,  to  affirm  that  because  the  symptoms  are  permanent  there  must  be 
some  organic  or  dynamic  lesion  is  a  fallacy.  I  hope  to  prove  that  the 
sensory  hysterical  symptoms  even  in  the  female  have  a  remarkable 
tenacity  just  as  in  the  male,  and,  also,  that  in  the  male,  depression  and 
a  tendency  to  melancholy  are  observed  very  often  in  markedly  hysterical 
cases,  and  that  the  variability  of  symptoms  is  not  the  rule"  (pp.  252-254). 
Some  very  instructive  cases  are  fully  described  to  substantiate  these 
positions.  Many  points  of  diagnosis  between  functional  and  organic 
affections  are  brought  out  incidentally  in  these  chapters,  and  those  which 
follow  upon  special  forms  of  hysteria.  Charcot  claims  the  credit  of 
originating  the  idea  of  the  treatment  of  hysteria  by  seclusion,  and  adds 
his  testimony  to  its  efficacy.  He  also  strongly  commends  hydrothera- 
peutic  measures. 

In  one  respect  this  volume  offers  a  contrast  to  the  first  two  volumes 
It  is  singularly  lacking  in  pathological  facts.  It  was  one  of  the  great 
merits  of  the  earlier  volumes  that  symptoms  and  lesions  were  brought 
into  a  logical  connection,  and  perhaps  their  great  success  was  due  to  the 
clear,  definite  pathological  facts  which  give  nervous  diseases  a  tangible 
basis.  The  lesions  of  hysteria  are  still  hypothetical,  and  hence  the  dis- 
cussion of  the  disease  is  still  unsatisfactory.  It  will  be  a  disappointment 
to  many,  that  no  attempt  is  made  in  this  volume  to  find  a  pathological 
basis  for  some  of  the  abnormal  functional  conditions  described.  But  the 
exact  description  of  symptoms  cannot  be  without  result,  and  in  this  re- 
spect this  volume  of  Charcot,  like  its  predecessors,  is  a  model  for 
clinicians.  M.  A.  S. 


A  Theoretical  and  Practical  Treatise  on  Astigmatism.  By  Swan 
M.  Burnett,  M.D.,  Professor  of  Ophthalmology  and  Otology  in  the  Uni- 
versity of  Georgetown,  D.  C.  With  fifty-nine  diagrams  and  illustrations. 
8vo.  pp.  viii.  246.    St.  Louis:  J.  H.  Chambers  &  Co.,  1887. 

In  this  book  of  two  hundred  and  fifty  pages,  the  author  has  given 
us  a  fair  treatise  on  astigmatism,  and  a  very  good  bibliography  of  the 
subject. 

The  body  of  the  work  is  divided  into  thirteen  chapters,  each  of  which 
has  its  separate  bibliography.  This  necessitates  a  good  deal  of  repeti- 
tion, the  same  paper  or  work  often  bearing  on  the  subject  matter  of 
several  chapters,  and  also  compels  the  reader  sometimes  to  look  over 
more  than  one  list  to  find  the  reference  sought.  This,  however,  is  not 
any  great  labor,  since  in  each  list  the  authors'  names  are  arranged  in 
alphabetical  order.  The  author,  in  the  preface,  states  his  belief  that  he 
has  recorded  here  "  the  title  of  every  important  paper  on  the  subject 
that  has  appeared  up  to  the  year  of  grace,  188H."  The  bibliography  is 
certainly  very  complete,  but  we  fail  to  find  in  it  any  mention  of  the 
brief  but  exceedingly  important  communication  of  Prof  Stokes  to  the 


506 


REVIEWS. 


British  Association  for  the  Advancement  of  Science,  in  which  he  de- 
scribed the  lens  that  has  since  borne  his  name. 

The  mathematical  portion  of  the  work  presupposes,  on  the  reader's 
part,  a  fair  acquaintance  with  the  elementary  principles  of  the  subject, 
yet  it  is  not  written  in  the  laconic,  rigid  style  often  adopted  in  treatises 
of  the  higher  mathematics,  and  which  is  found  most  pleasing  and  ser- 
viceable to  the  advanced  student;  but  the  whole  work  is  written  in  good 
English. 

To  one  who  has  studied  ophthalmology  by  the  aid  of  our  common  English 
text-books,  the  following  will  be  somewhat  startling  in  its  originality. 
"  The  asthenopia  of  astigmatism  is  of  two  kinds,  which  are  usually  de- 
nominated muscular  and  nervous.  The  first  named  form  has  its  seat  in 
the  muscle  of  accommodation,  being  sometimes  called  accommodative 
asthenopia,"  etc.  Now,  following  Grafe  and  Donders,  who  proposed 
these  terms,  we  have  been  accustomed  to  divide  asthenopia  into  accom- 
modative and  muscular ;  the  muscular  being  that  variety  which  is  not 
seated  in  the  muscle  of  accommodation,  but  is  wholly  independent  of  it, 
arising  in  connection  with  the  use  of  extra-ocular  muscles.  If  the  author 
desired  to  give  to  the  term  "  muscular  asthenopia  "  a  new  significance  ; 
and  deliberately  set  out  so  to  do,  we  think  he  should,  to  avoid  confusing 
his  readers,  have  given  due  notice  of  his  design.  But,  if  this  is  merely 
an  error  of  inadvertence,  it  leaves  a  fine  opportunity  for  improvement 
in  the  next  edition  of  the  book. 

The  cut  representing  the  appearance  of  the  fundus  of  an  astigmatic 
eye,  as  seen  by  the  direct  method  of  examination,  is  worthy  of  especial 
note  as  the  first  attempt,  among  many,  that  has  been  at  all  successful  in 
representing  the  appearance  in  question. 

The  student  can,  however,  get  a  still  better  conception  of  this  appear- 
ance, by  following  the  suggestion  of  the  author,  to  view  an  ordinary 
plate  of  the  normal  fundus  through  a  cylindrical  lens.  The  chapter  on 
irregular  astigmatism  and  conical  cornea  is  particularly  good,  though  it 
scarcely  does  justice  to  skiascopy,  as  the  shadow-test  is  called,  as  a  means 
of  diagnosis. 

In  an  appendix  is  given  a  statistical  record  of  806  astigmatic  eyes  be- 
longing to  475  different  individuals.  In  thirty-six  per  cent,  of  these  the 
lens  selected  gave  vision  up  to  the  normal  standard.  Not  a  very  high 
percentage  of  good  vision;  but  much  better  than  the  ten  per  cent,  stated 
in  the  text  as  the  proportion  attaining  this  standard,  this  smaller  pro- 
portion being  based  on  the  statistics  of  others.  Dr.  Burnett's  statistics 
would  be  of  more  value  if  they  represented  in  all  cases  the  absolute  re- 
fraction of  the  eye,  as  determined  under  a  mydriatic.  But  from  his  ex- 
pressed views  as  to  the  advisability  of  using  mydriatics  to  determine  the 
refraction,  it  is  fair  to  infer  that,  in  a  considerable  proportion  of  cases, 
only  the  manifest  astigmatism  has  been  ascertained;  and  this  inference 
becomes  certainty  when  we  see  that  fifty-seven  per  cent,  of  the  cases  are 
set  down  as  myopic  astigmatism.  E.  J. 


ZIEG-LER,   PATHOLOGICAL  ANATOMY. 


507 


Lehrbuch  der  Allgemeinen  und  Speciellen  Pathologischen  Ana- 
tomie.  By  Ernst  Ziegler,  Prof,  der  Pathologischen  Anatomie  und  der 
Allgemeinen  Pathologie  an  der  Universitat  Tubingen.  Fiinfte  Auflage. 
Bd.  ii.,  8vo.  pp.  499,  1020.    Jena :  Gustav  Fischer,  1887. 

A  Text-book  of  Pathological  Anatomy  and  Pathogenesis.  By 
Ernst  Ziegler.  Translated  and  Edited  for  English  students  by  Donald 
MacAlister,  M.A.,  M.D.  Part  II.  Special  Pathological  Anatomy.  Sec- 
tions ix.-xii.,  8vo.  pp.  391.    London  and  New  York  :  MacMillan  &  Co.,  1886. 

The  great  popularity  in  Germany  of  Ziegler's  General  and  Special 
Pathological  Anatomy,  is  attested  by  its  having  passed  through  five 
editions  in  six  years.  It  is  not  difficult  to  account  for  this  popularity. 
The  work  covers  all  the  subjects  of  both  general  and  special  patholog- 
ical anatomy ;  it  is  profusely  illustrated  with  admirable  drawings  ;  the 
style  is  clear  and  concise ;  the  arrangement  of  the  text  is  perspicuous 
and  well  adapted  for  the  use  of  students;  the  abundant  use  of  different 
sizes  of  type  forces  upon  the  attention  the  points  intended  to  be  empha- 
sized; the  subject  matter  is  a  vivid  presentation  of  the  author's  views 
based  largely  upon  his  own  researches  and  is  not  a  mere  reproduction  of 
all  current  doctrines  in  pathology;  and  the  book  is  kept  fully  abreast  of 
the  most  recent  advances  in  pathological  science. 

The  book  has  been  much  improved  in  the  fifth  edition  by  many  addi- 
tions and  alterations,  by  changes  in  arrangement  and  by  the  insertion  of 
new  drawings,  which  now  Dumber  703.  The  changes  are  greatest  in  the 
first  volume  which  treats  of  general  pathological  anatomy. 

The  numerous  drawings  of  microscopical  specimens,  many  of  them 
colored,  were  made  by  the  author  and  are  excellent.  It  is  especially  to 
be  commended  that  those  made  with  low  magnifying  powers  predom- 
inate. Less  praise  can  be  given  to  the  drawings  of  macroscopic  speci- 
mens, of  which  a  large  number  of  new  ones  have  been  added  to  the 
present  edition.  These  are  of  very  unequal  merit,  and  some  are  posi- 
tively bad,  such  as  the  drawing  of  the  pearl  disease  of  cattle  (Fig.  309, 
Vol.  II.),  of  which  the  gross  appearances  are  very  characteristic. 
Nevertheless,  the  employment  of  a  larger  number  of  macros copical 
drawings  greatly  enhances  the  value  of  the  work. 

By  the  introduction  of  a  section  on  the  Pathological  Anatomy  of  the 
Eye,  by  Haab,  and  one  on  the  Pathological  Anatomy  of  the  Ear,  by 
Wagenhauser,  the  work  is  made  to  embrace  all  departments  of  patho- 
logical anatomy.  It  can  not  be  said,  however,  that  the  amount  of  space 
given  to  the  various  subjects  is  altogether  commensurate  with  their  im- 
portance. While,  for  instance,  six  pages  are  devoted  to  speculations  con- 
cerning the  inheritance  of  acquired  conditions  (essentially  the  views  of 
Weismann  being  adopted),  the  diseases  of  the  nose  are  dismissed  in  scant 
three  pages,  and  a  short  paragraph  suffices  for  neuroparalytic  keratitis,  a 
subject  of  much  interest  from  the  standpoint  of  both  general  and  special 
pathology.  How  interesting  and  important  is  the  pathological  anatomy 
of  the  nasal  cavity,  may  be  learned  by  a  perusal  of  the  sixteen  pages  on 
this  subject  in  Orth's  recent  work  on  Special  Pathological  Anatomy.  It 
would  have  added  to  ease  of  reference  and  to  the  completeness  of  the 
book  to  have  brought  together  in  a  compendious  form  the  lesions  of 
some  of  the  more  important  infectious  diseases,  and  those  following 


508 


REVIEWS. 


various  organic  and  inorganic  poisons,  as  has  been  done  in  Birch- 
Hirschfeld's  text-book  of  Pathological  Anatomy. 

Ziegler's  text-book  is  characterized  especially  by  the  prominence  given 
to  histological  details,  particularly  to  the  finer  cellular  changes,  such  as 
those  occurring  in  the  processes  of  hyperplasia,  regeneration,  and  inflam- 
mation. We  miss  the  clear,  full,  and  accurate  descriptions  of  gross 
pathological  appearauces,  such  as  distinguish  Forster's  classical  Hand- 
buck  der  Pathologischen  Anatomie,  as  a  new  edition  of  which  Ziegler's 
text-book  was  originally  intended.  Nor  in  respect  to  the  happy  com- 
bination of  gross  anatomical  and  of  histological  descriptions  does  Zieg- 
ler's work  compare  favorably  with  Orth's  Lehrbuch  der  Speciellen  Patho- 
logischen Anatomie,  of  which  the  first  volume  has  recently  appeared. 

The  rearrangement  in  this  edition  of  the  chapters  in  the  first  volume 
is  a  decided  improvement,  although  we  can  not  understand  why  the  sub- 
ject of  embolism  should  be  placed  in  a  chapter  entitled  "  General  Con- 
siderations Concerning  the  Etiology  and  the  Genesis  of  Diseases."  It  is 
somewhat  significant  that  the  chapter  treating  of"  Malformations"  should 
immediately  follow  that  devoted  to  "  Tumors,"  as  indicating  that  these 
morbid  conditions  are  perhaps  akiu,  although  Ziegler  does  not  accept  in 
its  entirety  Cohnheim's  hypothesis  concerning  the  origin  of  tumors. 

In  his  interesting  treatment  of  the  subject  of  "  Regeneration,"  as  well  as 
in  other  parts  of  the  book,  Ziegler  shows  the  important  role  played  by 
karyokinesis  in  pathological  processes.  Cohnheim's  doctrine  of  inflam- 
mation is  accepted  in  its  essential  features.  The  only  origin  of  pus  cells 
admitted  by  Ziegler  is  the  emigration  of  white  blood  corpuscles.  Cells 
intended  for  the  formation  of  new  tissue  are  derived  partly  by  prolifera- 
tion from  the  fixed  cells  and  partly  from  leucocytes,  but  of  the  latter 
only  certain  kinds,  particularly  the  uninuclear  ones,  are  capable  of  for- 
mative activity. 

It  is  especially  characteristic  of  the  recent  direction  of  pathological 
studies  that  no  less  than  118  pages  of  the  new  edition  are  devoted  to  the 
description  of  bacteria,  in  contrast  to  60  pages  allotted  to  this  subject  in 
the  fourth  edition  published  less  than  two  years  previously.  In  the  pre- 
paration of  the  section  on  bacteriology  the  author  acknowledges  his  in- 
debtedness to  the  new  edition  of  Fliigge's  Mikroorganismen. 

The  pathological  anatomy  of  the  brain  and  that  of  the  spinal  cord  and 
of  their  meninges  are  considered  together.  This  arrangement  saves  repe- 
tition, but  it  is  often  confusing  and  is  less  satisfactory  than  to  describe 
the  lesions  of  each  organ  separately.  Ziegler  attempts  to  clear  up  some 
of  the  confusion  which  has  been  introduced  ioto  this  department  of 
pathological  anatomy  by  clinicians.  Especially  praiseworthy  is  his  sepa- 
ration from  myelitis  of  various  atrophic  and  degenerative  processes  which 
have  been  erroneously  placed  in  this  category  by  clinical  writers. 

The  chapter  on  the  pathological  anatomy  of  the  lungs,  although  in 
many  respects  good,  will  commend  itself  less  favorably  to  pathologists 
than  the  admirable  treatment  of  the  same  subject  by  Orth  in  the  work 
already  mentioned.  Ziegler  regards  the  micrococcus  Pasteuri  of  Stern- 
berg (whose  name  Is  nowhere  mentioned  in  the  book  in  connection  with 
this  organism),  as  the  cause  of  most  cases  of  croupous  pneumonia, 
although  the  bacillus  pneumoniae  of  Friedlander  and  the  streptococcus 
pyogenes  may  be  occasional  causes.  Fibrous  induration  is  described  as 
a  not  infrequent  termination  of  croupous  pneumonia,  without  any  con- 
sideration of  the  arguments  of  Wagner  and  others  that  these  cases  of  dif- 


SMITH,  ABDOMINAL 


SURGERY. 


509 


fuse  interstitial  inflammation  differ  from  the  ordinary  cases  of  croupous 
pneumonia.  The  statement  that  miliary  tubercles  of  the  lungs  always 
begin  in  the  pulmonary  parenchyma  (connective  tissue  and  inter- 
alveolar  septa)  and  the  accompanying  illustration  (p.  680;  are  in  oppo- 
sition to  the  convincing  researches  of  Arnold  and  of  Baumgarten  on 
this  point.  Much  described  and  pictured  as  broncho-pneumonia  in 
the  chapter  on  pulmonary  tuberculosis  would  be  much  better  designated 
tubercle. 

The  ordinary  classification  of  Bright's  diseases  into  acute  nephritis, 
chronic  parenchymatous  nephritis,  and  chronic  indurative  nephritis  or 
contracted  kidney  is  adopted.  The  frequency  is  ignored  of  patches  of 
atrophy  and  of  increased  interstitial  tissue  in  the  kidneys  grouped  under 
the  heading  of  chronic  parenchymatous  nephritis,  a  designation  which  is 
rendered  of  doubtful  propriety  by  the  existence  of  these  changes. 

Ziegler  was  wise  in  selecting  an  ophthalmologist  to  contribute  the 
"  Pathological  Anatomy  of  the  Eye,"  for  this  subject  can  not  be  treated 
satisfactorily  by  one  not  familiar  with  ophthalmoscopical  appearances. 
Haab  has  presented  in  a  brief  but  satisfactory  manner  a  department  of 
pathological  anatomy  of  great  interest  and  one  too  much  neglected  by 
professional  pathologists.  The  pathological  anatomy  of  the  ear  is 
treated  too  aphoristically  to  afford  more  than  a  bird's-eye  view  of  the 
subject. 

In  view  of  its  many  external  and  not  a  few  internal  merits,  Ziegler 's 
Pathological  Anatomy  cannot  fail  to  prove  attractive  to  medical  students, 
as  has  already  been  demonstrated ;  with  teachers  and  investigators  in 
pathology  it  is  not  likely  to  occupy  so  high  a  rank  as  some  of  its  pre- 
decessors and  competitors. 

English  readers  are  to  be  congratulated  upon  the  completion  of  Dr. 
MacAlister's  translation  of  Ziegler's  text-book,  of  which  the  first  two 
volumes  have  already  been  reviewed  in  this  journal,  and  the  volume 
containing  sections  ix.  to  xii.  has  since  been  published.  The  sections 
treating  of  the  pathological  anatomy  of  the  eye,  ear,  bones,  muscles,  and 
genital  organs  have  not  been  translated,  on  the  ground  that  these  subjects 
pertain  to  surgical  pathology.  In  the  translation  of  the  concluding 
volume  advantage  was  taken  of  the  improvements  in  the  fourth  German 
edition.  W.  H.  W. 


.Abdominal  Surgery.  By  J.  Greig  Smith,  MA.,  F.R.S.E.,  Surgeon  to  the 
British  Royal  Infirmary ;  Late  Examiner  in  Surgery,  University  of  Aber- 
deen ;  Fellow  of  the  Royal  Medical  and  Chirurgical  Society,  London,  etc. 
8vo.  pp.  600.    Philadelphia:  P.  Blakiston,  Son  &  Co.,  1887. 

This  volume  will  supply  a  much  desired  want,  not  only  to  the  prac- 
tical gynecologist,  but  also  to  the  general  medical  reader,  who  may  wish 
to  inform  himself  as  to  the  progress  of  abdominal  surgery.  Written  in 
a  simple,  clear,  and  condensed  style,  and  covering  almost  the  entire 
range  of  abdominal  operations,  the  work  has  already  attracted  the  atte  n- 
tion of  many  American  readers,  who  appear  inclined  to  regard  it  favor- 
ably, although  coming  from  the  pen  of  a. young  man,  as  yet  little  known 
on  this  side  of  the  Atlantic.    Although  very  credit  able  to  its  composer, 


510 


REVIEWS. 


we  feel  in  our  criticism  inclined  to  draw  attention  to  certain  minor 
points,  which  ought  to  be  corrected  in  a  second  edition. 

Silkworm  gat  has  not  in  this  country  stood  the  test  of  experience  as 
a  suture  material  for  the  abdominal  wound.  When  carefully  prepared 
and  shot-clamped,  it  will  occasionally  produce  "stitch-hole  abscesses" 
which  are  at  times  long  in  closing,  and  for  this  reason  some  operators 
have  abandoned  it  for  the  silver  wire.  Certain  snoods  appear  to  be  in- 
fected, either  by  reason  of  impurities  received  in  their  preparation,  or  it 
may  be,  by  disease  in  the  silkworm  itself,  and  the  most  careful  asepsis 
will  at  times  be  disappointing.  Where  a  drainage-tube  is  used,  a  long 
unsecured  suture  should  be  inserted  opposite  the  centre  of  the  tube,  to 
be  twisted  or  shotted  after  its  removal. 

The  author  remarks  with  reference  to  Mr.  Lawson  Tait's  first  oophor- 
ectomy (August  1,  1872) :  "  By  some  mistake,  Battey  records  this  r.ase 
as  being  fatal  "  (page  147).  Dr.  Battey,  in  The  Medical  Neivs  of 
July  24,  1886,  page  110,  says,  "this  is  another  slip  of  the  pen:  at  no 
time  have  I  said  that  this  patient  died." 

"  Though  Thomas  and  others  claim  to  have  diagnosticated  the  condi- 
tion (extrauterine  pregnancy)  before  rupture,  it  is  unfortunately  the 
case  that  the  first  sign  of  it  usually  appears  at  rupture"  (page  159). 
American  gynecologists  are  particularly  sensitive  upon  the  subject  of 
their  ability  to  recognize  an  early  Fallopian  pregnancy  by  the  history, 
sensations,  and  touch.  One  of  the  fetuses  destroyed  under  the  galvanic 
current  by  Prof.  T.  G.  Thomas,  has  proved  the  correctness  of  his  diag- 
nosis, by  escaping  from  the  rectum.  Twice  have  we  seen  early  foetal 
cysts  exsected  in  this  city,  before  rupture,  after  a  careful  diagnosis.  The 
words  "  claim  to  "  should  be  omitted. 

"  One  operator  has  had  recourse  to  the  doubtful  expedient  of  making 
space  by  turning  the  bowels  outside  the  abdomen  altogether"  (page  169). 
This  is  quite  a  common  practice  with  the  best  American  operators,  in 
cases  where  working  space  is  wanted,  care  being  taken  to  cover  the  in- 
testines within  a  warm,  prepared  cloth,  and  to  keep  them  warm  until 
returned.    We  have  seen  this  done  repeatedly,  and  no  ill  effect  follow. 

The  Improved  Cozsarean.  "A  sufficient  number  of  cases  has  not  yet 
been  recorded  to  enable  us  finally  to  judge  of  the  risks  of  this  operation" 
(page  259).  Possibly  the  author  may  not  be  aware  that  55  operations 
have  been  reported,  with  39  women  saved,  and  50  children  delivered 
alive.  Last  year  (1886)  there  were  22  cases,  with  4  deaths.  These 
figures  promise  well. 

In  laparo-elytrotomy  the  bladder  has  been  lacerated  in  one-half  of  the 
cases  (6),  instead  of  one-third  (4),  as  stated  on  page  261. 

"  The  results  so  far,"  in  primary  laparotomy  for  extrauterine  preg- 
nancy, "have  been  17  operations  with  15  deaths"  (page  284).  We  will 
increase  the  first  figure  to  26,  and  give  the  foetal  loss  as  14. 

Mr.  Holmes  did  not  (Feb.  21,  1885)  first  supply  to  English  readers, 
as  stated  on  page  335,  an  account  of  Prof.  Pietro  Loreta's  operation  of 
digital  divulsion  of  the  pylorus,  unless  the  word  "  English  "  be  intended 
in  a  national  sense.  Prof.  Loreta  read  the  first  account  of  his  opera- 
tion on  Feb.  11,  1883,  and  on  April  21,  1883,  a  full  statement,  with  a 
record  of  four  cases,  was  published  by  the  reviewer,  under  a  request 
from  Bologna,  in  The  Medical  News,  pp.  434-438.  Prof.  Loreta  has 
of  later  years  made  his  abdominal  incision  in  the  linea  alba,  whether 
for  pyloric  or  cardiac  stenosis.   These  operations  must  always  be  limited 


AMERICAN 


GYNECOLOGICAL 


SOCIETY. 


511 


mainly  to  Italy,  for  the  reason  that  the  conditions  calling  for  them  are 
much  more  common  there  than  in  the  rest  of  Europe. 

The  illustration  of  the  Czerny  intestinal  suture  on  page  412  is  incor- 
rect, as  it  is  to  be  passed  through  the  mucous  membrane.  This  error  is 
not  to  be  wondered  at,  as  it  is  found  also  in  Treves,  on  Intestinal  Ob- 
struction, 1884,  p.  485,  and  in  Sanger's  "  Der  Kaiserschnitt  bei  Uterus- 
fibromen,"  1882.  The  Czerny-Lembert  suture  will  be  found  described 
in  The  Medical  News  of  May  21,  1887,  p.  588. 

Dr.  E.  Hahn,  of  Berlin  (April,  1881),  was  not  the  first  to  perform 
the  operation  of  nephrorrliaphy,  as  stated  on  page  457,  as  this  was  done  in 
Mobile,  Alabama,  prior  to  1870.  The  kidney  broke  loose  from  its 
anchorage,  and  was  removed  by  Dr.  John  T.  Gilmore,  in  December, 
1870,  who  found  a  cicatrix  in  the  organ,  two  inches  long,  where  the  tape 
had  cut  its  way  out.  The  nephrectomy  was  entirely  successful.  Dr. 
Gilmore  failed  to  give  the  name  of  the  operator  who  preceded  him  in 
the  case. 

We  are  glad  not  to  have  found  any  errors  of  vital  moment  in  Mr. 
Smith's  creditable  work,  which  bears  the  evidence  of  an  extensive  and 
painstaking  research  in  the  literature  of  America  and  the  chief  coun- 
tries of  Europe.  It  will,  no  doubt,  be  very  extensively  read  in  this 
country,  and  is  of  special  value  for  its  teaching  in  diagnosis. 

E.  P.  H. 


Transactions  of  the  American  Gynecological  Society,  for  the 
Year  1886.    Vol.  II.  8vo.  pp.  516.    New  York :  D.  Appleton  &  Co.,  1887. 

This  Society  now  consists  of  58  active  and  15  honorary  Fellows.  Its 
last  annual  meeting  was  held  in  Baltimore,  on  September  21,  22,  and 
23,  1886,  at  which  there  were  present  29  Fellows. 

As  our  allotted  space  will  not  admit  of  a  resume  of  the  papers  read, 
we  will  confine  our  remarks  to  a  few  of  the  more  striking.  Dr.  Henry 
P.  C.  Wilson  excited  the  attention  of  the  Fellows,  and  provoked  a  pro- 
longed and  chiefly  adverse  discussion,  by  reading  a  paper  in  which  he 
advocated  the  old  plan  of  incising  the  posterior  lip  of  the  cervix  uteri, 
"  in  some  forms  of  anteflexion  of  the  uterus,  with  dysmenorrhea  and 
sterility,"  based  upon  an  experience  of  over  four  hundred  cases  in  eighteen 
years. 

Dr.  Ellwood  Wilson,  of  Philadelphia,  recommended  an  application  of 
nitrate  of  silver  in  strong  solution,  one  drachm  to  the  ounce,  at  intervals 
of  five  days,  several  times  repeated,  as  a  means  of  healing  recent  lacera- 
tions of  the  cervix  uteri,  and  gave  an  account  of  six  cases  thus  satisfac- 
torily treated,  thereby  avoiding  a  resort  to  trachelorrhaphy. 

Dr.  John  Goodman,  of  Louisville,  read  a  paper  in  condemnation  of 
the  use  of  ergot,  at  the  close  of  the  third  stage  of  labor,  based  upon  the 
results  in  two  cases,  one  ending  fatally,  in  which  he  had  administered  it. 
His  opinion  gave  rise  to  a  long  discussion,  in  which  the  weight  of  testi- 
mony was  in  favor  of  the  use  of  the  drug  in  moderate  doses. 

The  paper  of  Dr.  Fordyce  Barker,  on  "  The  Influence  of  Maternal 
Impressions  on  the  Foetus,"  was  listened  to  with  much  attention  and 
discussed  at  great  length.    The  subject  is  one  of  the  curiosities  of  ob- 


512 


REVIEWS. 


stetrics  and  embryology,  and  much  was  brought  forward  that  would 
appear  to  make  it  possible  for  a  maternal  impression  to  show  itself  in 
the  foetus,  after  the  period  when  embryology  teaches  us  that  the  growth 
of  the  body,  arms,  and  legs  has  advanced  to  their  completeness  of  devel- 
opment. Coincidences  are  often  very  singular  and  difficult  to  explain, 
and  so  the  post  hoc  propter  hoc  argument  is  resorted  to.  We  confess  to 
being  rather  sceptical  upon  this  subject,  except  as  to  the  effect  of  im- 
pressions experienced  in  the  early  formative  stage  of  the  embryo. 

Dr.  John  Byrne,  of  Brooklyn,  gave  his  experience  in  the  use  of  the 
galvano-cautery  in  the  treatment  of  procidentia  uteri,  in  which  he  ap- 
pears to  have  met  with  very  marked  success.  In  one  case  he  amputated 
the  cervix  close  up  to  the  insertion  of  the  vagina  ;  in  a  second,  he  burned 
a  gutter  around  the  cervix  with  a  platinum  knife,  and  then  partially 
amputated  the  cervix  at  the  bottom  of  the  groove  by  a  platinum  loop 
heated  moderately ;  and  in  three  other  cases,  in  addition  to  the  partial 
amputation,  the  vagina  was  grooved  by  the  cautery  knife,  making  three 
diverging  fissures,  one  central,  one  toward  either  side  on  the  anterior, 
and  one  only  on  the  rectal  surface,  for  a  distance  of  about  three  inches, 
and  through  the  hypertrophied  vaginal  membrane. 

The  long  paper  of  the  volume  is  that  of  Dr.  George  J.  Engelmann, 
of  St.  Louis,  entitled  "  The  Use  of  Electricity  in  Gynecological  Prac- 
tice," which  covers  149  pages.  This  is  followed  by  one  of  12  pages  on 
u  Electrolysis  in  Gynecological  Surgery,"  by  Dr.  William  H.  Baker,  of 
Boston,  based  upon  the  treatment  by  galvanopuncture  of  14  cases  of 
uterine  fibroids.  Dr.  Baker  advocates  puncturing  at  intervals  of  one, 
two,  or  three  months.  In  one  of  bis  cases  the  tumor  entirely  disappeared ; 
in  twelve  it  diminished  from  one-third  to  a  half;  and  in  the  remaining 
case  there  was  little  or  no  effect.  He  also  reported  the  successful  treat- 
ment by  the  same  method,  of  a  case  of  perimetritic  effusion,  after  failure 
in  obtaining  relief  under  the  ordinary  treatment  recommended  in  such 
cases. 

"  Persistent  Pain  after  Abdominal  Section,"  is  the  title  of  a  paper  by 
Dr.  James  B.  Hunter,  of  New  York.  This  is  a  subject  of  much  interest, 
but  the  cause  is  sometimes  unaccountable.  Operations  for  the  relief  of 
pain  fail,  and  in  some  cases  a  cure  follows  a  long  period  of  suffering. 
The  ligature  has  no  doubt  much  to  do  with  the  production  of  pain  in 
some  sensitive  subjects. 

Dr.  James  R.  Chadwick,  of  Boston,  demonstrated  the  value  of  the 
bluish  color  of  the  vaginal  entrance  as  evidence  of  pregnancy,  shown  by 
his  examination  of  281  pregnant  women.  The  color  was  absent  in  31, 
and  doubtful  in  28  cases ;  in  42  it  was  characteristic,  and  a  general  deep 
tint  existed  in  102. 

Dr.  W.  H.  Parish,  of  Philadelphia,  reported  a  Cesarean  operation, 
and  made  a  statement  in  reference  to  the  growing  mortality  under  this 
method  of  delivery,  and  the  reasons  for  it,  in  the  United  States. 

The  unusual  number  of  seven  papers  were  contributed  to  the  volume 
by  candidates  for  admission  to  fellowship.  We  are  glad  to  see  this 
increase  in  the  Society,  and  the  introduction  of  new,  young,  and  active 
workers  to  take  the  places  of  those  recently  lost  by  death  and  resigna- 
tion. R.  P.  H. 


DIMMER.   OPHTHALMOSCOPIC  DIAGNOSIS. 


513 


Der  Augexspiegel  ukd  die  Ophthalmoskopische  Diagxostik.  Von 
Dr.  F.  Dimmer,  Docent  in  d.  Wiener  Universitat,  etc.  Pp.  175,  with  73 
illustrations.    Leipzig  und  Wien,  1887. 

The  Ophthalmoscope  and  Ophthalmoscopic  Diagnosis.  By  Dr.  F. 
Dimmer. 

We  confess  to  great  disappointment  in  this  book.  When  a  teacher  in 
the  great  Vienna  school,  of  many  years'  experience,  writes  a  treatise  we 
have  a  right  to  expect  some  actual  contribution  to  our  knowledge.  We 
do  not  look  for  a  rehash  of  what  has  been  wTitten  ever  so  many  times 
before  and  often  better,  and  yet  this  is  what  a  Docent  in  the  University 
of  Vienna  and  an  assistant  of  the  great  Arlt  oners  us. 

The  only  things  which  could,  even  by  courtesy,  be  called  new,  are  the 
description  of  Schmidt-Rimpler's  method  of  determining  refraction  by  the 
indirect  method  of  ophthalmoscopic  examination,  and  a  good  description 
of  skiascopy,  or  retinoscopy,  as  he  calls  it,  both  of  which  could  be  ob- 
tained equally  well  from  other  sources  at  the  command  of  the  student. 
In  the  descriptions  of  changes  in  the  fundus,  constant  references  are  made 
to  the  atlases  of  Jager  and  Liebreich,  the  possession  of  which  is  neeessary 
for  the  understanding  of  the  text.  A  most  natural  and  pertinent  ques- 
tion is,  If  the  reader  has  the  atlases  with  the  descriptions  of  the  authors, 
what  need  has  he  for  Dr.  Dimmer's  descriptions  ? 

S.  M.  B. 


Hysterie  et  Traumatism.    Par  le  Dr.  Paul  Berbez.    8vo.  pp.  127. 

Paris  :  A.  Delahaye  et  Lecrosnier,  1887. 
Hysteria  axd  Traumatism.    By  Dr.  Paul  Berbez. 

The  surgical  aspects  of  hysteria,  under  which  title  the  author  includes 
paralysis,  contractures,  and  joint  affections  of  hysterical  nature  develop- 
ing after  injuries,  have  recently  been  studied  by  Charcot,  and  this  little 
brochure  by  one  of  his  pupils  contains  an  interesting  review  of  the  sub- 
ject. It  covers  a  portion  of  the  ground  included  in  Page's  work  on 
railroad  injuries. 

The  author  finds  the  real  cause  of  all  hystero-traumatic  phenomena 
in  the  special  mental  condition  preceding  the  injury,  and  thinks  that  the 
injury  itself  has  little  to  do  with  the  special  form  of  disease  developed, 
since  in  many  cases  no  evidence  of  trauma  is  found  and  the  result  is  out 
of  all  proportion  to  the  severity  of  the  injury.  Age,  sex,  occupation, 
race,  and  temperament  have  nothing  to  do  with  the  etiology,  but  emo- 
tional excitement,  especially  fear,  is  a  potent  factor  in  the  production  of 
these  effects. 

Monoplegia  is  the  form  of  paralysis  most  frequently  seen  ;  it  is  remark- 
able for  its  completeness,  and  the  limb  is  perfectly  helpless  and  flaccid  ; 
the  tendon  reflexes  are  preserved  or  diminished,  never  lost ;  the  loss  of 
motion  is  accompanied  by  a  total  loss  of  sensation  and  of  the  muscular 
sense;  to  the  latter  symptom  the  author  attaches  much  importance  in 
diagnosis.    Paraplegia  may  occur  and  paralysis  of  a  part  of  one  limb 

NO.  CLXXXVIII. — OCTOBER,  1S87.  33 


514 


REVIEWS. 


is  occasionally  seen ;  in  the  latter  case  it  is  one  segment  of  the  limb  which 
is  affected  and  not  the  muscles  in  the  distribution  of  one  nerve,  as  in 
true  traumatic  cases.  In  all  cases  the  electric  excitability  of  the  muscles 
is  preserved ;  their  mechanical  excitability  is  increased,  but  not  infre- 
quently a  slight  atrophy  occurs ;  the  temperature  of  the  limb  may  fall, 
it  may  become  cyanotic  and  the  nutrition  of  the  skin  may  be  changed, 
but  bedsores  do  not  form.  Paraplegia  also  occurs.  Paralysis  with  con- 
tracture is  the  second  form  considered  with  its  attendant  deformities. 
In  this  condition  voluntary  motions  are  very  limited  and  are  unable  to 
diminish  the  contractures  or  to  affect  the  deformity ;  there  is  often  au 
increase  of  the  reflexes,  and  general  sensibility  is  abolished  except  over 
certain  irregular  zones  which  are  not  uniform.  Desquamation  of  the 
skin  is  often  seen,  and  a  progressive  atrophy  of  the  muscles  without 
change  in  electric  excitability  is  noticed. 

When  paralysis  with  contracture  is  associated  with  pain  in  the  joint 
the  condition  is  termed  arthralgia,  and  this  resembles  so  closely  organic 
lesions  of  the  joint  that  diagnosis  is  often  difficult.  The  pain  continues 
during  rest,  it  is  increased  by  motion,  its  distribution  is  the  same  as  in 
real  joint  disease,  the  attitude  and  deformity  are  identical  with  those  in 
joint  disease,  and  the  only  differential  sign  of  value  is  the  existence  of 
hyperesthesia  of  the  skin  around  the  joint  and  on  the  limb.  But  under 
ether  all  the  signs  of  joint  disease  disappear,  and  hence,  anesthetics  offer 
the  chief  aid  to  diagnosis. 

The  author  cites  a  large  number  of  cases  in  illustration  of  these  con- 
ditions. An  interesting  fact  discovered  by  Charcot  is  that  all  these 
forms  of  disease  can  be  produced  by  suggestion  in  hypnotized  persons, 
a  fact  which  seems  to  him  to  prove  that  the  mental  state  and  not  any 
physical  condition  is  the  underlying  cause  of  all  such  affections.  The 
conditions  produced  by  suggestion  may  include  abolition  of  motor  power, 
with  preservation  or  exaggeration  of  the  tendon  reflexes,  and  persistence 
of  the  electrical  excitability,  and  also  total  loss  of  sensations  of  touch, 
temperature,  pain,  and  of  the  muscular  sense.  Such  a  condition  has  no 
tendency  to  recover  spontaneously  and  it  is  only  by  counter-suggestion 
in  the  hypnotized  state  that  it  can  be  removed.  The  character  of  the 
paralyses  and  contractures  thus  produced  is  identical  with  that  of  those 
occurring  after  injuries  in  hysterical  patients.  It  is,  therefore,  evident 
that  the  latter  have  a  psychical  origin.  In  the  hypnotized  state  the 
brain  is  in  a  semisomnolent  condition ;  attention,  consciousness,  judg- 
ment, and  will  are  weak  ;  memory,  imagination,  and  emotion  are  active. 
The  brain  then  acts  only  from  incoming  sensations  or  suggestions  with 
little  or  no  control.  Tell  the  person  hypnotized  that  he  cannot  move 
his  arm,  and  the  idea  of  powerlessness  takes  possession  of  his  mind  and 
neutralizes  all  the  ideas  of  movement  which  former  experience  has  given 
him.  The  same  is  true  of  the  person  injured,  except  that  it  is  the  injury 
which  acts  as  the  cause  of  the  idea  of  weakness. 

It  is  evident  that  explanations  such  as  this  may  be  probable,  but  are 
hypothetical,  and  that  all  attempts  of  the  kind  are  unsatisfactory.  The 
facts,  however,  are  of  interest.  Nor  is  it  any  better  to  assign  as  a  cause 
of  contracture  a  "  diathese  de  contracture  "  or  a  "  special  excitability  of 
the  spinal  cord."  It  is,  perhaps,  fortunate  that  the  various  phenomena 
of  hysteria  are  being  so  carefully  studied  by  the  French  school,  but  we 
cannot  but  think  that  M.  Berbez,  like  many  of  his  confreres,  is  unable 
to  give  a  theory  to  account  for  the  facts  which  will  resist  criticism.  In 


MEYER,   DISEASES   OF   THE  EYE. 


515 


regard  to  treatment  of  these  cases,  it  is  evident  that  it  must  be  directed 
to  the  mental  state.  It  is  possible  to  act  on  this,  however,  by  physical 
means,  and  hydrotherapy  and  electricity,  with  massage,  are  the  measures 
considered  by  the  author  as  of  greatest  service.  M.  A.  S. 


The  Topographical  Anatomy  of  the  Child.  By  Johnson  Symington, 
M.D.,  F.R.S.E.,  Lecturer  on  Anatomy,  School  of  Medicine,  Edinburgh. 
Edinburgh,  1887. 

This  magnificent  work  forms  one  of  the  most  important  and  most 
valuable  of  the  recent  contributions  to  human  anatomy.  Topographical 
anatomy  is  usually  considered  independently  of  the  age  and  sex  of  the 
subject,  and  there  can  be  no  question  that  many  of  its  data  require 
reconsideration. 

The  present  work  is  founded  upon  the  examination  of  a  series  of 
frozen  sections  of  the  bodies  of  children.  It  is  illustrated  by  fourteen 
life-sized  colored  plates,  and  by  a  number  of  woodcuts.  Of  the  excel- 
lence and  fidelity  of  the  plates  it  is  impossible  to  speak  too  highly. 
They  reflect  the  greatest  credit  upon  the  publishers. 

The  vertical  medial  sections  and  some  coronal  sections  of  the  thorax 
are  the  most  valuable.  Sections  are  given  of  all  parts  of  the  trunk  ;  of 
the  skull,  to  show  the  orbits  and  nasal  fossse ;  of  the  neck,  to  show  the 
position  of  the  larynx  ;  of  the  thorax,  abdomen,  and  pelvis. 

The  first  part  of  the  work  is  devoted  to  a  critical  explanation  of  the 
plates.  The  second  part  deals  systematically  with  the  more  conspicuous 
results  of  the  author's  investigations.  The  topographical  anatomy  of 
the  auditory  meatus  and  tympanum,  the  condition  of  the  spinal  curve 
in  children,  the  topography  of  the  brain,  and  the  relational  anatomy  of 
the  male  and  female  genital  organs,  are  all  dealt  with  in  au  able  and 
original  manner. 

Dr.  Symington's  book  abounds  in  original  material.  It  is  a  work 
that  no  anatomist  can  afford  to  overlook.  It  adds  materially  to  our 
knowledge  of  the  most  practical  branch  of  anatomy,  and  is  a  credit  to 
modern  scientific  research.  F.  T. 


A  Practical  Treatise  on  Diseases  of  the  Eye.  By  Dr.  Edouakd 
Meyer,  Prof  a  l'Ecole  pratique  de  la  Faculte  de  Medecine  de  Paris,  etc. 
Translated,  with  the  assistance  of  the  Author,  by  Freeland  Feeu  us, 
M.D.,  Ophthalmic  Surgeon,  Glasgow  Royal  Infirmary,  etc.  8vo.,  pp.  650. 
Philadelphia :  P.  Blakiston,  Son  &  Co.,  1887. 

In  his  brief  preface  the  author  tells  us  this  work  was  prepared  for  the 
press  nearly  fifteen  years  ago,  and  that  portions  of  it  had  then  already 
been  published  ;  but  so  thoroughly  has  this  English  edition  been  revised, 


516 


REVIEWS. 


and  so  well  has  it  been  brought  up  to  the  present  state  of  our  knowl- 
edge, that  this  would  not  be  suspected  from  a  perusal  of  the  work. 

A  somewhat  elaborate  classification  of  the  diseases  of  the  eye  is  em- 
bodied in  the  book,  involving  its  division  into  chapters  and  articles,  and 
the  latter  by  headings,  subheadings,  sub-subheadings,  and  paragraphs ; 
but  the  arrangement  of  the  various  parts  is  natural,  aud  a  good  index 
gives  the  intelligent  reader  direct  access  to  all  parts  of  its  store  of  infor- 
mation ;  fitting  it  to  be  the  reference  book  of  the  practitioner  who  does 
not  hold  himself  especially  familiar  with  this  branch  of  medical  prac- 
tice. And  this  function,  of  a  work  of  reference  for  the  general  prac- 
titioner, is  the  one  this  book  is  particularly  fitted  to  perform.  In  this 
direction  it  is  eminently  "  a  practical  treatise."  But  for  the  student 
desirous  of  mastering  the  subject  of  refraction,  or  the  use  of  the  ophthal- 
moscope, the  first  essential  steps  in  the  preparation  for  ophthalmic  prac- 
tice, it  would  prove  rather  an  unsatisfactory  manual.  For  instance, 
while  we  are  given  cuts  and  descriptions  of  the  binocular  ophthalmoscope 
of  Giraud-Teulon,  the  fixed  ophthalmoscope  of  Liebreich,  and  the  oph- 
thalmoscope for  two  observers  of  Sichel,  instruments  that  have  served 
merely  to  demonstrate  the  ingenuity  of  their  inventors,  and  to  take  up 
the  pages  of  "  systematic"  treatises  on  ophthalmology  for  the  last  quarter 
of  a  century,  not  a  single  modern  refraction  ophthalmoscope  is  figured, 
or  even  mentioned ;  and  the  shadow-test  gets  but  a  brief,  obscure,  inac- 
curate allusion,  under- the  name  of  Skiaskopia.  Color-blindness,  too,  re- 
ceives but  little  attention. 

An  excellent  feature  of  the  work  is  the  giving,  before  the  considera- 
tion of  the  diseases  of  each  part,  of  a  clear,  succinct  account  of  such  points 
in  its  anatomy  as  bear  directly  on  the  pathology,  diagnosis,  or  treatment 
of  those  diseases.  A  case  of  this  kind,  where  diagnosis  and  therapeutics 
will  be  fixed  by  a  knowledge  of  anatomy,  is  presented  in  hyperemia 
involving  the  white  of  the  eye.  Here,  when  the  injection  is  most  pro- 
nounced back  from  the  cornea  near  the  fold  of  the  conjunctiva,  as  it 
passes  from  the  eyeball  on  to  the  lids,  and  the  enlarged  vessels  form  an 
irregular  network  freely  movable  over  the  deeper  sclerotic,  the  trouble 
is  conjunctival.  But  when  the  pink  coloration  is  deepest  and  most  dis- 
tinct at  the  margin  of  the  cornea,  where  the  individual  vessels  are  scarcely 
visible,  while  from  this  marginal  zone,  straighter,  less  movable  vessels 
radiate  backward  toward  the  retrotarsal  fold,  the  centre  of  disease  in- 
volves the  cornea,  iris,  or  ciliary  body ;  and  the  case  is  much  more 
serious,  and  demands  different  treatment.  Dr.  Meyer  brings  out  this 
point  in  diagnosis,  and  illustrates  it  very  well  by  a  diagrammatic  repre- 
sentation of  the  two  kinds  of  hyperemia,  both  separately  and  coexistent. 

We  note  in  passing  that  our  author  is  a  believer  in  amblyopia  ex 
anopsia,  and  even  attempts  to  trace  its  disastrous  progress. 

The  translator  has  done  his  part  carefully  and  well.  The  colored 
plates  are  selections  from  Liebreich's  Atlas .  of  Ophthalmoscopy,  and  are 
well  executed,  as  are  also  the  woodcuts,  and,  indeed,  the  printing 
throughout.  E.  J. 


QUARTERLY  SUMMARY 

OF  THE 

PEOGKESS   OF  MEDICAL  SCIENCE. 


ANATOMY. 


UNDER  THE  CHARGE  OF 

GEOEGE  D  THANE,  M.RC.S.  Eng., 

PROFESSOR  OF  ANATOMY  AT  UNIVERSITY  COLLEGE,  LONDON. 


On  the  Synovial  Sheath  of  the  Eadial  Extensors  of  the  Wrist. 

In  the  Revue  de  Chirurgie  for  1882,  Larger  described  a  second  synovial 
sheath  to  the  radial  extensor  tendons,  surrounding  them  where  they  are  crossed 
above  the  wrist  by  the  thumb-muscles.  Debierre  and  Rochet  state 
(Archives  de  Physiologie  for  February,  1887)  that  they  did  not  find  this  sheath 
in  any  one  of  more  than  forty  subjects  examined ;  but  in  all  cases  there  was 
a  small  bursa,  which  Larger  refers  to  as  accidental,  between  the  tendons  of 
the  radial  extensors  and  the  extensor  ossis  metacarpi  and  primi  internodii 
pollicis.  This  bursa  is  the  ordinary  seat  of  painful  ganglion  in  this  region. 
The  synovial  sheath  of  the  radial  extensors  beneath  the  annular  ligament  is 
usually  single,  but  occasionally  double.  It  always  communicates  with  the 
sheath  around  the  extensor  secundi  internodii  pollicis,  the  aperture  being 
placed  over  the  tendon  of  the  extensor  carpi  radialis  brevior,  and  leading 
into  the  inner  division  only  of  a  double  sheath. 

On  the  Nervous  Supply  of  the  Lumbricales. 

H.  St.  John  Brooks  shows  that  the  nervous  supply  of  the  lumbricales  in 
the  hand  is  subject  to  frequent  variations,  and  that  the  current  statements 
with  regard  to  the  nerves  of  these  muscles  in  the  foot  are  incorrect.  In  the 
hand,  the  prevalent  condition  is  for  the  median  nerve  to  supply  the  first  and 
second,  and  the  deep  part  of  the  ulnar  the  third  and  fourth ;  but  in  many 
cases  the  third  lumbrical  has  a  branch  from  the  median  as  well  as  one  from 
the  ulnar.  More  rarely  the  second  has  also  a  double  supply ;  or,  on  the  other 
hand,  the  median  supplies  wholly  the  first,  second,  and  third,  and  the  ulnar 
the  fourth  only.  Ten  feet  were  examined,  and  in  nine  of  these  only  the  first 
lumbrical  was  supplied  by  the  internal  plantar,  the  rest  deriving  their  nerves 
from  the  deep  part  of  the  external  plantar.    In  the  tenth  case  the  first  and 


518 


PROGKESS  OF   MEDICAL  SCIENCE. 


second  muscles  received  twigs  from  both  plantar  nerves ;  the  third  and  fourth 
from  the  external  alone.  The  author  believes  that  originally  all  the  lumbri- 
cales  were  supplied  on  their  superficial  surface,  and  that  the  deep  nerve  is 
gradually  displacing  the  superficial,  thus  illustrating  Cunningham's  proposi- 
tion that  in  mammals  the  ulnar  and  external  plantar  nerves  are  encroaching 
upon  the  territory  of  the  median  and  internal  plantar  respectively.  There  is 
an  evident  general  correspondence  between  the  innervation  of  a  particular 
belly  of  the  flexor  profundus  and  of  the  corresponding  lumbrical:  the  indicial 
belly  and  the  first  lumbrical  are  supplied  exclusively  by  the  median ;  the 
fourth  belly  and  fourth  lumbrical  are  supplied  typically  by  the  ulnar  only ; 
and  the  third  belly  and  lumbrical  have  usually  a  double  supply ;  but  while 
the  same  is  the  case  with  the  second  belly,  it  is  very  exceptional  in  the  second 
lumbrical  {Journal  of  Anatomy  and  Physiology,  July,  1887). 

On  the  Pharyngeal  Orifice  of  the  Eustachian  Tube. 

Casimir  von  Kostanecki  deals  with  the  cartilaginous  and  membranous 
portion  of  the  Eustachian  tube  in  a  long  article,  illustrated  by  twenty-four 
figures  showing  different  forms  of  its  pharyngeal  ending.  The  paper  consists 
of  detailed  descriptions,  and  cannot,  therefore,  be  satisfactorily  abstracted ; 
but  the  chief  general  points  are  as  follows  : 

The  position  of  the  pharyngeal  orifice  is  not  the  same  at  different  periods 
of  life,  and  is  subject  to  many  individual  variations.  It  often  differs  some- 
what on  the  two  sides  in  the  same  person.  The  distance  from  the  anterior 
nasal  spine  varies  from  5.3  to  7.5  cm.  Vertically,  its  most  frequent  position 
is  behind  the  inferior  concha,  at  an  average  distance  of  10  mm.  above  the 
hard  palate;  but  it  is  sometimes  behind  the  middle,  at  others  behind  the  in- 
ferior meatus.  In  the  foetus  the  orifice  is  below  the  hard  palate ;  at  birth  on 
the  same  level.  From  the  roof  of  the  pharynx  the  average  distance  is  11  to  12 
mm. ;  the  extremes  9.5  to  15  mm.  From  the  hinder  wall  of  the  pharynx, 
10  to  19  mm.;  average,  12  mm.  From  the  inferior  concha,  4  to  14^5  mm.;  in 
children  under  one  year,  7.5  to  10.5  mm. 

The  typical  form  of  the  opening  is  that  of  a  triangle,  the  upper  angle  of 
which  is  rounded  off  slightly,  while  the  base  below  is  convex  upward,  owing 
to  the  projection  of  the  belly  of  the  levator  palati  toward  the  lumen.  The 
two  lower  angles  are  thus  prolonged  as  grooves  along  the  floor  of  the  tube 
and  the  upper  surface  of  the  soft  palate — sulcus  salpingo-palatinus,  anterior 
and  posterior. 

The  anterior  or  outer  lip  of  the  orifice  is  frequently  indistinguishable,  the 
outer  wall  of  the  tube  being  continued  directly  into  the  side  wall  of  the  nose ; 
but  in  the  great  majority  of  cases  it  is  marked  by  a  distinct  fold — plica  salpingo- 
palatina,  determined  by  a  fibrous  band,  the  ligamentum  salpingo-palatinum 
anticum. 

The  opening  of  the  tube  is  affected  by  the  tensor  palati,  levator  palati,  and 
salpingo-pharyngeus.  The  contraction  of  the  levator  raises  the  floor  of  the 
tube,  and  so  reduces  the  vertical  diameter  of  the  orifice,  but  at  the  same  time 
it  pushes  upward  the  inner  plate  of  the  cartilage,  thus  making  the  lumen 
wider. 

The  recess  of  Rosenmiiller,  or  sinus  faucium  lateralis,  varies  in  depth  from 


MATERIA    MEDICA   AND   THERAPEUTICS.  519 


0  to  17  mm.,  and  is  continued  downward  by  a  groove  which  is  named  sulcus 
pharyngo-oralis  lateralis.  In  addition  to  the  foregoing,  the  sinus  faucium  supe- 
rior of  Tortual  is  recognized,  a  small  depression  above  the  prominent  end  of 
the  tube  (Archivfur  mikroskopische  Anatomie,  June,  1887). 


MATERIA  MEDICA,  THERAPEUTICS,  AND 
PHARMACOLOGY. 


UNDER  THE  CHARGE  OF 

ROBEBTS  BAETHOLOW,  M.D.,  LL.D., 

PROFESSOR  OF  MATERIA  MEDICA,  GENERAL  THERAPEUTICS,  AND  HYGIENE  IN 
THE  JEFFERSON  MEDICAL  COLLEGE,  PHILADELPHIA. 


Stenocarpine  ;  A  New  axd  Powerful  Anesthetic  and  Analgesic  of 
Indigenous  Source. 

The  most  remarkable  discovery  since  Koller's  demonstration  of  the  anal- 
gesic power  of  cocaine,  is  that  just  made  by  Mr.  Goodman,  a  veterinary 
surgeon  of  Louisiana,  and  Dr.  Allen  M.  Seward,  of  Bergen's  Point, 
New  Jersey.  Mr.  Goodman  ascertained,  by  the  merest  accident,  that  anal- 
gesic and  anaesthetic  properties  were  possessed  by  the  leaves  of  a  tree,  known 
in  the  locality  where  it  grows,  as  the  "Tear  Blanket  Tree."  Obviously,  this 
designation  is  significant  of  the  injury  done  by  the  sharp  spines,  with  which 
the  tree  is  plentifully  garnished.  It  is  greatly  to  Mr.  Goodman's  credit  that 
he  had  the  sagacity  to  observe  and  to  reason  from  his  facts.  The  leaves  of 
the  tree  were  submitted  to  Dr.  Seward,  who  isolated  an  alkaloid,  to  which  he 
gave  the  name  stenocarpine. 

The  physiological  actions  of  stenocarpine  have  been  carefully  studied  by 
Dr.  Claiborne  and  Dr.  Knapp,  both  of  New  York.  Their  conclusions 
agree  closely  for  the  most  part.  A  two  per  cent,  solution,  with  which  Dr. 
Claiborne  was  supplied,  was  employed  by  both  investigators,  Dr.  Knapp 
having  obtained  a  small  quantity  from  his  colleague.  As  the  powers  and 
properties  of  cocaine  are  so  well  known,  a  comparison  of  the  new  anaesthetic 
with  its  older  cogener  will  develop  their  respective  qualities  the  more  fully, 
and  by  the  contrast,  when  differences  are  found,  more  characteristically. 

Stenocarpine  acts  as  an  analgesic  and  anaesthetic  when  applied  in  solution 
to  the  mucous  membrane  at  any  point.  Dr.  Claiborne  asserts  that  it  has  the 
same  influence  on  the  sensibility  of  the  skin  ;  but  Dr.  Knapp  did  not  find  it 
so,  although  his  negative  result  may  be  attributed  to  the  small  quantity  of  the 
alkaloid  with  which  he  operated.  When  a  plentiful  supply  of  the  new  alka- 
loid becomes  available,  this  question  can  be  easily  and  finally  settled.  Injected 
beneath  the  skin,  an  anaesthetic  area  is  produced,  having  the  limits  which  the 
extent  of  the  diffusion  determines,  as  is,  also,  the  case  with  cocaine. 

When  applied  to  the  conjunctiva  the  anaesthetic  effect  takes  place  in  from 
five  to  ten  minutes,  and  in  from  ten  to  fifteen  minutes  the  pupil  dilates  and 
the  accommodative  apparatus  becomes  paretic  and  then  paralyzed.    As  com- 


520 


PROGRESS   OF   MEDICAL  SCIENCE. 


pared  with  cocaine,  the  effects  of  stenocarpine  on  the  pupil  and  on  the  accom- 
modation are  far  greater.  The  dilatation  of  the  pupil  is  nearly  equal  to  that 
produced  by  atropine,  but  it  is  not  as  persistent.  In  certain  cases  the  pupil 
of  the  other  eye  contracts  to  a  mere  pin's  head  in  size.  The  anaesthetic  and 
analgesic  effects  are  quite  equal  to  those  of  cocaine  in  corresponding  strength. 

Stenocarpine  is  more  actively  toxic  than  cocaine.  It  causes  tetanic  spasms 
not  unlike  those  of  strychnine  (Knapp) ;  but  the  tetanoid  paroxysms  are  ac- 
companied by  trembling,  weakness,  and  incoordination,  and,  finally, paralysis 
ensues — a  fact  that  indicates  exhaustion  of  the  centres,  at  first  stimulated. 
Very  rapid  action  of  the  heart  occurs,  probably  because  stenocarpine  para- 
lyzes the  pneumogastric,  and  thus  removes  the  inhibition.  As  the  effects 
deepen,  paresis  of  the  respiratory  muscles  comes  on,  and  ultimately  they  become 
paralyzed,  the  action  of  the  heart  failing  after  respiration  has  ceased. 
Although  additional  observations  are  needed  to  settle  the  nature  of  the  influ- 
ence exerted  on  the  respiration  and  circulation  by  stenocarpine,  there  is  little 
doubt  that  the  explanation  above  given  will  prove  to  be  true. 

Knapp's  observations  on  the  therapeutical  applications  of  the  new  remedy, 
and  the  comparison  between  it  and  the  actions  of  cocaine,  are  characteristically 
thorough,  and  have  an  enduring  interest  for  all  those  practising  ophthal- 
mology.   We  have  space  here  for  the  principal  points  only. 

Whenever,  with  the  actions  of  an  anaesthetic,  a  mydriatic  is  required,  as  in 
iritis,  stenocarpine  is  preferable  to  cocaine.  It  is  also  better  than  atropine 
when  there  is  a  tendency  to  glaucoma,  and  much  pain  is  felt.  When,  however, 
an  anaesthetic  is  necessary,  and  a  mydriatic  is  not,  then  cocaine  becomes  more 
useful ;  and  this  condition  of  affairs  includes  all  the  ophthalmic  surgical  pro- 
cedures. As  stenocarpine  is  nearly  as  powerful  as  atropine  in  dilating  the 
pupil,  and  as  its  influence  continues  only  about  half  as  long,  it  is  preferable 
to  atropine  for  this  purpose. 

It  need  hardly  be  explained  that  stenocarpine  can  be  substituted  for  cocaine 
as  a  local  anaesthetic  in  the  numerous  maladies  for  which  a  local  anaesthetic 
is  needed.  If  it  shall  be  proven  hereafter  that  in  a  sufficiently  concentrated 
solution  stenocarpine  anaesthetizes  the  skin,  as  well  as  the  mucous  membrane, 
it  will  assume  the  first  place  as  a  local  anaesthetic  and  analgesic. 

It  must  be  stated  also  that  some  subjects  possess  a  remarkable  susceptibility 
to  the  actions  of  stenocarpine.  This  fact  is  true  also  of  cocaine.  In  a  few 
instances,  when  stenocarpine  has  been  instilled  into  the  eyes,  weakness,  faint- 
ness,  a  cold  sweat,  and  a  rapid  but  feeble  action  of  the  heart  have  ensued,  as 
it  is  so  powerful.  Knapp  utters  a  caution,  and  advises  that  it  be  not  injected 
into  very  vascular  tissues. 

SOLANTN. 

The  active  principle  solanin,  although  long  known  as  a  constituent  of  the 
potato  in  its  fresh  state,  has  received  but  little  attention.  Last  year,  however, 
Dr.  Geneuil  published  a  paper  [Bull.  Gen.  de  Therap.  for  September,  1886) 
in  which  he  ascribed  very  valuable  anodyne  and  hypnotic  qualities  to  solanin. 
To  confirm  or  refute  the  conclusions  arrived  at  by  Dr.  Geneuil,  an  elaborate 
investigation  was  made  by  Dr.  Gaignard  in  the  laboratory  of  the  Hopital 
Cochin  under  the  direction  of  Dujardin-Beaumetz.    We  have  the  result  now 


MATERIA   ME  DIC  A   AND  THERAPEUTICS. 


521 


in  a  paper  which  appears  in  the  current  issue  of  the  Bull.  Gen.  de  Th'erap. 
of  July  15th.    Unfortunately,  the  conclusions  are  negative,  chiefly. 

Dr.  Gaignard  says  that  solanin  is  a  glucoside,  which  does  not  combine  with 
acids  to  form  salts. 

It  is  absolutely  insoluble  in  simple  water,  and  soluble  only  in  strongly 
acidulated  water. 

It  is  highly  irritating  to  the  tissues. 

It  is  uncertain  in  action,  and  only  massive  doses  will  produce  an  analgesic 
effect.  At  its  best,  solanin  is  not  a  useful  analgesic.  Moreover,  it  is  an  ex- 
pensive remedy,  and  relatively  large  doses  are  required  to  produce  an  effect. 
The  ordinary  dose  is  from  one  to  three  grains,  and  the  daily  amount  ranges 
from  four  to  eight  grains. 

Solanin,  it  is  clear,  cannot  be  regarded  as  useful  in  itself,  or  as  a  substitute 
for  another  remedy. 

Effects  of  Hyoscine. 

Kobert,  in  a  recent  number  of  the  Archiv  f.  experiment.  Pathol,  u.  Pharmacol., 
vol.  xxii.,  narrates  his  experiences  with  hyoscine.  There  are  two  sources  of 
this  alkaloid  :  From  the  mother  liquor  out  of  which  the  alkaloid  hyoscyamine 
has  crystallized,  and  synthetically  by  the  process  of  Ladenburg.  The  latter 
source  is  a  mere  matter  of  scientific  interest.  The  hyoscine  of  the  first 
source  is  an  amorphous,  resin-like  substance,  but  it  has  all  the  activity  of  a 
crystallizable  alkaloid.  It  is  isomeric  with  atropine  and  hyoscyamine,  and  it 
acts  like  the  former  on  the  vagus,  and  on  the  heart  of  warm-blooded  animals. 
It  does  not  act  on  the  vasomotor  centre  in  the  medulla,  nor  does  it  affect  the 
pulse  frequency.  The  salivary  and  the  sweat-glands  are  acted  on,  and  their 
secretions  arrested.  It  paralyzes  the  motor-nerve  apparatus  of  the  intestine, 
when  stimulated  by  muscarine. 

Hyoscine  acts  more  promptly  and  thoroughly  on  the  pupil  than  atropine 
does,  but  the  mydriatic  effect  is  much  shorter  in  duration.  On  the  brain  of 
healthy  persons  it  has  a  weak  narcotic  property.  In  morbid  states  of  the 
brain  hyoscine  is  found  to  lessen  excitement,  and  to  bring  about  sleep  in  ten 
to  fifteen  minutes,  and  its  hypnotic  action  may  prove  successful  when  chloral, 
the  bromides,  paraldehyde,  and  urethan  have  failed.  It  is,  therefore,  highly 
useful  to  calm  the  excitement  in  cases  of  mania,  but  in  somatic  diseases  with 
wakefulness  it  is  of  doubtful  utility.  Edlefsen  and  Illing  prescribe  it  when 
the  chief  indications  are  furnished  by  spasmodic  cough,  asthma,  epilepsy,  etc. 

In  animals  hyoscine  is  not  at  all  actively  toxic,  and  in  man  the  indications 
afforded  by  dilatation  of  the  pupil,  incoordination  of  movements,  dryness  of 
the  throat,  etc.,  appear  long  in  advance  of  any  danger. 

Injection  for  Gonorrhoea. 
Delpech  proposes  the  following  injection  for  the  treatment  of  gonorrhoea  : 

R. — Hydrarg.  ammoniat.  peptonic   gr. 

Aquae  destil  3vi. — M. 

Directions  for  use:  Take  an  injection  morning  and  evening  after  passing 
urine.  The  first  and  second  injection  should  be  allowed  to  escape  ;  the  third 
one  should  be  retained  in  the  canal  a  minute  or  two.  This  procedure  should 
be  carried  out  twice  each  day — morning  and  evening. 


522 


PKOGRESS   OF   MEDICAL  SCIENCE. 


Massotherapy. 

Under  the  newly  coined  title  massotherapy  Dujardhst-Beaumetz  dis- 
courses on  massage  [Bull.  Gen.  de  Therapeutique,  July  15, 1887).  He  presents 
an  interesting  historical  summary  from  Hippocrates  down,  showing  how  in 
this,  as  in  so  many  other  points  of  practice,  our  modern  discoveries  are  only 
revivals  of  ancient  usages.  One  of  the  most  curious  of  the  works  referred 
to  is  that  of  Paullini,  Flagellum  Salutis,  which,  a  century  afterward,  was  re- 
published by  Meibomius  (1795),  under  the  French  title  which  may  be  thus 
rendered :  The  Utility  of  Flagellation  in  Medicine  and  the  Pleasures  of  Marriage, 
and  in  the  Functions  of  the  Loins  and  Kidneys.  This  title  will  recall  the  man- 
ner in  which  the  Town  Bull  is  stimulated  to  the  performance  of  his  public 
functions,  as  narrated  in  an  English  classic. 

The  physiological  effects  of  massage  are  exerted  on  the  functions  of  the 
skin,  the  muscular  system,  the  circulation,  the  nervous  system,  absorption, 
and  nutrition.  As  respects  the  skin,  he  refers  to  the  mechanical  displace- 
ment of  the  epidermic  cells,  and  the  opening  of  the  orifices  of  the  sebaceous 
and  sudoriparous  glands,  the  principal  utility  of  the  practice,  which  thus  in- 
creases the  circulation  and  functional  activity  of  the  cutaneous  apparatus. 
The  tone  of  the  muscles,  their  contractile  energy,  their  nutrition,  are  im- 
proved by  the  movements  of  which  they  are  the  subject.  The  increased 
activity  of  the  circulation  in  the  skin  and  muscles  promotes  oxidation  and 
combustion,  and  hastens  the  removal  of  effete  materials.  The  increase  of  the 
peripheral  circulation  reacts  on  the  central  apparatus,  and  hence  there  is 
greater  activity  with  higher  temperature  of  the  whole  body. 

The  effect  of  massage  on  the  nervous  system  is  twofold,  consisting  in 
pressure,  friction,  and  elongation  of  nerve  trunks,  and  in  a  peculiar  mental 
state,  called  by  Barety,  whom  our  author  quotes,  neurisation.  Now,  Barety 
entitles  his  work  Animal  Magnetism,  and  ascribes  a  certain  influence  to 
"passes,"  thus  reviving  and  bringing  into  the  terms  of  science  antiquated 
mesmeric  jargon.  If  this  is  to  be  the  outcome  of  massage,  it  were  high  time 
to  call  a  halt. 

On  the  pathological  side,  the  usual  effect  of  massage  on  local  inflammatory 
deposits,  effusions,  etc.,  are  duly  set  forth  by  Dujardin-Beaumetz. 

Hypnotism. 

The  jugglery  of  hypnotism,  and  its  medico-legal  relations,  are  the  subject  of 
a  recent  work  by  Gilles  de  la  Tourette,  to  which  an  introduction  has 
been  written  by  Prof.  Brouardel.  A  French  critic  has  well  said  that  this 
subject  has  become  "an  object  of  commerce,  transportable  and  lucrative," 
and  that  the  "  commercial  travellers  of  hypnotism  "  are  doing  infinitely  more 
mischief  than  is  supposed;  so  much  so,  that  the  Austrian  and  Italian 
governments  have  forbidden  the  exercise  of  their  arts.  It  is  not  a  hopeful 
indication  that  the  methods  and  terms  of  Mesmer  are  again  proposed  as  a  re- 
medial agency.  It  is  a  fact  that  under  the  leadership  of  Dr.  Elliotson,  of 
London,  the  mesmeric  trance  was  utilized  for  the  production  of  insensibility 
for  surgical  operations,  and  the  announcement  of  anaesthesia  by  ether,  just 
discovered  in  this  country,  was  made  in  the  London  Medical  Gazette,  under  the 
title  "Animal  Magnetism  Superseded."    But  this  occurred  in  1848. 


MATEKIA   MEDICA   AND  THERAPEUTICS. 


523 


Iodide  of  Potassium  ix  the  Broxcho-pxeumoxia  of  Childrex. 

Dr.  Zixis,  of  Athens,  Greece,  in  a  letter  which  appears  in  a  recent  issue  of 
the  Bull.  Gen.  de  Therapeutique,  advocates  the  use  of  iodide  of  potassium  in 
the  broncho-pneumonia  of  children,  making  some  reservations,  however,  as 
to  the  form  of  the  disease.  He  asserts  that  a  perfect  cure  of  the  disease  is 
more  certainly  accomplished  by  this  than  by  any  other  remedy,  especially  if 
used  early.  He  finds  that  it  lowers  the  temperature  one  to  two  degrees,  that  it 
sensibly  diminishes  the  cough,  and  calms  the  respiration,  and  that  it  renders 
the  expectoration  easier.  He  makes  the  reservation  that  the  broncho-pneu- 
monia of  measles  and  whooping-cough  is  not  so  amenable  to  the  action  of  this 
remedy.  He  finds  also  that  the  results  are  better  when  the  child  is  vigorous, 
and  when  the  age  is  above  rather  than  under  five  years.  These  are  important 
exceptions,  and  very  much  limit  the  utility  of  the  remedy.  It  is,  however, 
no  secret  in  this  country  that  small  and  frequently  repeated  doses  of  the 
iodides  are  of  great  utility  in  cases  of  capillary  bronchitis. 

The  quantity  of  the  remedy  recommended  by  Dr.  Zinis  to  be  given  in 
twenty-four  hours  varies,  according  to  the  age,  from  eight  grains  to  a  scruple, 
dissolved  in  three  ounces  of  water. 

Apropos  of  the  use  of  the  iodides  in  the  bronchitis  of  children,  M.  H.  Eoger 
advises  the  following : 

R. — Syrupi  amyli  iodidi  Jfiv. 

Potassii  iodidi     .       .       .       .  .       .    gr.  xv. — M. 

Before  each  meal  a  coffeespoonful  of  this  syrup.  Every  morning  ^  grain 
granule  of  arseniate  of  soda  in  a  cup  of  milk  ;  and  at  each  meal  two  ounces 
of  raw  beef  and  half  a  drachm  of  phosphate  of  lime  in  powder. 

The  Actioxs  of  the  Crystallizable  Veratrum  Alkaloids. 

Dr.  Heixrich  Lissauer  publishes,  in  the  last  issue  of  the  Archiv  fiir 
experimentellc  Pathologic  und  Pharmacologic,  an  elaborate  research  on  the 
actions  of  the  crystallizable  veratrum  alkaloids.    We  submit  his  conclusions : 

These  alkaloids  paralyze  the  vasomotor  apparatus,  including  the  vasomotor 
centre  in  the  medulla,  and  probably,  also,  directly  the  organic  muscular  fibre 
of  the  vessels. 

They  slow  the  action  of  the  heart  without  enfeebling  it,  if  the  doses 
exhibited  are  not  so  large  as  to  paralyze  directly. 

They  affect  the  respiratory  action,  at  first  merely  slowing  and  lengthening 
the  interval,  but  at  last  complete  paralysis  ensues. 

The  movements  of  the  peripheral  muscles  are  affected  in  a  similar  manner. 

The  digestive  tract  is  influenced  variously  in  different  animals  :  in  some 
there  is  merely  salivation  ;  in  others,  nausea,  vomiting,  and  diarrho?a. 

By  large  doses,  spasms  centric  in  source  are  produced. 

Temperature  is  affected,  and  without  doubt  in  a  secondary  manner,  through 
the  action  on  the  vascular  apparatus  and  the  function  of  assimilation. 

We  do  not  find  that  our  author  has  contributed  any  new  facts  to  the  exist- 
ing knowledge  of  the  effects  caused  by  the  veratrum  alkaloids. 


524 


PROGRESS   OF    MEDICAL  SCIENCE. 


The  German  and  French  Treatment  of  Asthma  Compared. 

Dr.  Schlemner  {Revue  de  Th&rapeutique,  June  15,  1887)  makes  a  com- 
parison between  German  and  French  therapeutical  methods  as  applied  to  the 
treatment  of  asthma.  As  regards  the  reflex  influences  which  determine 
attacks  of  asthma,  especially  morbid  states  of  the  nasal  mucous  membrane, 
they  seem  to  receive  more  attention  from  German  than  French  therapeutists. 

In  the  treatment  of  the  asthmatic  paroxysm,  both  employ  the  inhalation  of 
pyridine  and  the  subcutaneous  injection  of  morphine  and  cocaine.  Lazarus, 
who  has  but  little  confidence  in  such  remedies  as  paraldehyde,  hyoscyamine, 
atropine,  and  quebracho,  praises  chloral  and  iodide  of  potassium.  Whilst 
the  French  employ  with  success  the  rectal  injections  of  sulphuretted  hydrogen, 
there  are  no  reports  from  Germany  of  similar  experiences. 

Besides  the  iodides  and  pyridine,  some  German  authorities  use,  also,  arsenic 
and  lobelia.  Briigelmann  insists  on  the  importance  of  pneumotherapy,  espe- 
cially when  catarrh  and  emphysema  complicate  the  case  ;  Lazarus  especially 
vaunts  nitrogen  and  saline  inhalations,  and  terpine  ;  and  Lublinsky  advocates 
the  treatment  of  the  accompanying  neurasthenia  or  constitutional  states,  and 
in  this  practice  Boecker  and  other  physicians  coincide. 

Ulexine. 

Gerrard  has  recently  separated  an  alkaloid  from  Ulex  europsens,  to  which 
the  name  ulexine  has  been  given.  This  new  principle  has  been  investigated 
by  Mr.  J.  Eose  Bradford,  whose  paper  appears  in  the  current  issue  of  the 
Journal  of  Physiology  for  June,  1887,  vol.  viii.  No.  2. 

The  hydrobromate  is  the  salt  used  in  these  investigations.  It  was  ascer- 
tained by  experiments  on  frogs,  that  ulexine  paralyzes  muscle3,  and  nerve 
trunks,  and  depresses  the  spinal  cord  somewhat.  In  sufficient  doses,  it  first 
arrests  voluntary  movements  and  the  reflex  actions,  but  the  muscles  continue 
to  contract  feebly  on  direct  excitation,  unless  the  dose  be  very  large,  when 
they  too,  are  immediately  poisoned.  In  cold-blooded  animals — frogs  and  eels 
— ulexine  paralyzes  the  vagus,  and  the  heart  is  also  slowed  and  weakened. 

Ulexine  acts  on  the  respiration  in  a  peculiar  manner,  and  in  a  minute  quan- 
tity, not  sufficient  to  affect  voluntary  movements,  causes  paresis,  irregularity, 
and  slowness  of  respiration.  In  the  words  of  our  author — "  with  larger  doses 
the  respirations  will  be  arrested  some  time  before  voluntary  movement  is 
paralyzed." 

In  mammals  ulexine  is  a  powerful  respiratory  poison  also.  Small  doses 
caused  fibrillar  contractions  of  the  muscles  of  a  very  persistent  character, 
and  at  first  the  muscles  respond  with  an  abnormal  readiness  to  mechanical 
irritation,  but  this  stage  of  excitation  is  succeeded  by  paresis,  and,  finally, 
complete  paralysis  succeeds. 

Ulexine  increases  the  blood  pressure  very  considerably  and  quickly  if  the 
amount  given  be  small,  but  this  rise  is  succeeded  by  a  gradual  fall.  When  a 
large  quantity  is  given  the  rise  in  the  blood  pressure  is  inconsiderable,  and 
the  fall  is  greater  and  longer  in  duration.  Mr.  Bradford  ascertained  that 
there  ensues  a  marked  contraction  of  the  kidney  simultaneously  with  the  rise 
in  the  blood  pressure,  and,  hence,  he  concludes  that  this  phenomenon  is  due 
to  contraction  of  the  arterioles. 


MATERIA 


MEDICA 


AND  THERAPEUTICS. 


525 


When  the  vagus  can  no  longer  inhibit  the  heart's  action,  the  pulsations 
become  very  rapid,  but  weak.  The  kidney  contracting  with  the  rise  of  pres- 
sure, it  again  expands  with  the  fall.  Ulexine  is  an  active  diuretic,  and  can 
best  be  compared  with  caffeine,  but  the  latter  has  a  more  sustained  influence. 
Our  author  concludes  his  paper  with  the  following  sentence,  which  is  a  com- 
pendious statement  of  the  facts  and  a  summary  of  his  final  opinions : 

"  Thus  ulexine  is  an  alkaloid,  having  a  powerful  and  widespread  action, 
being  a  nerve  and  muscle  poison,  a  respiratory  poison,  raising  arterial  tension, 
and  producing  diuresis  ;  but  the  respiratory  action  of  the  drug  being  pro- 
duced by  the  smallest  doses,  seems  to  be  the  most  important." 

Glycerine  and  Diabetes. 

In  the  last  issue  of  The  Journal  of  Physiology  Mr.  W.  B.  Eansom  discusses 
the  influence  of  glycerine  on  the  sugar-producing  function  of  the  liver. 
Weiss  and  Luchsinger  had  before  demonstrated  that  under  the  action  of 
glycerine  an  accumulation  of  glycogen  took  place  in  the  liver ;  and,  subse- 
quently, Luchsinger  and  Eckhard  ascertained  that  experimental  glycosuria 
was  sometimes  prevented  by  the  subcutaneous  injection  of  glycerine. 

After  a  careful  investigation  of  the  subject  by  experimental  work,  Mr. 
Eansom  has  formulated  the  following  conclusions  : 

"1.  That  certain  forms  of  glycosuria  may  be  checked  by  glycerine. 

"2.  That  glycerine  acts  more  efficiently  when  introduced  into  the  alimen- 
tary canal  than  when  injected  subcutaneously. 

"  3.  That  glycerine  checks  glycosuria  by  inhibiting  the  formation  of  sugar 
in  the  liver. 

"  4.  That  in  this  way  glycerine  may  lead,  indirectly,  to  an  accumulation  of 
glycogen  in  the  liver." 

Mr.  Eansom  holds  that  the  production  of  glycogen  in  the  liver  is  due  to 
cell  metabolism  and  not  to  the  action  of  a  ferment.  The  action  of  glycerine, 
he  thinks,  consists  in  some  modification  in  the  protoplasm  of  the  liver-cells. 
He  has  no  opinion  to  express  as  to  the  therapeutical  value  of  glycerine  in 
diabetes,  and  the  views  of  clinicians  are  both  various  and  conflicting.  It  is 
quite  probable,  the  reviewer  thinks,  that  some  change  in  the  quantity  given 
and  in  the  manner  of  giving  it  will  place  glycerine  amongst  the  most  valuable 
of  the  remedies  for  diabetes. 

Treatment  of  Angina  Pectoris. 

In  a  recent  issue  of  the  Revue  de  Therapeutigue,  we  find  a  compendious 
statement  of  Dr.  Huchard's  opinions  on  the  subject  of  cardiac  diseases 
remediable  by  the  iodides.  In  his  picturesque  phrase,  "these  are  maladies 
that  have  the  heart  for  their  seat,  and  the  arteries  for  their  origin."  The 
treatment  by  the  iodides  is  first  concerned  with  relieving  that  condition  of  the 
vessels  which  prevents  a  proper  interchange  between  the  blood  and  the 
tissues  ;  afterward  with  the  muscular  substance  (myocarditis).  Besides  those, 
he  includes  a  group  in  which,  whilst  the  rational  signs  are  significant,  there 
are  no  physical  signs  of  the  mitral  disease.  The  present  conception  of  its 
clinical  characteristics  is  indicated  in  the  title — arterial  cardiopathy — which 
is  applied  to  a  group  including  the  coronary  arteries,  the  muscular  substance 


526 


PROGRESS   OF   MEDICAL  SCIENCE. 


of  the  heart,  and  the  aorta.  They  have  these  clinical  characteristics  in  com- 
mon :  as  expressed  in  the  language  of  Huchard — "  they  are  latent  in  their 
evolution,  insidious  in  their  origin,  paroxysmal  in  their  course,  accidental  and 
intermittent  in  their  manifestations,  sudden  and  destructive  in  their  explosions 
of  arhythmic  irregularity."  The  heart  suffers  secondarily  to  the  alterations 
which  begin  in  the  arterial  system.  It  follows  necessarily  that  to  confine  the 
treatment  to  the  heart  is  to  fail.  It  is  less  a  cardiac  medication  than  an  arte- 
rial to  which  our  treatment  should  be  addressed,  and  this  conception  is  as 
applicable  to  the  treatment  of  angina  pectoris  as  to  all  other  diseases  included 
within  the  great  morbid  process  called  arteriosclerosis. 

Hydroquinone. 

Dr.  Silvestrini  and  Dr.  Picchini,  his  pupil,  have  published  (II  Mor- 
gagni  and  Revue  de  Therapeutique,  July  15,  1887)  some  recent  observations  on 
hydroquinone.  This  chinoline  derivative  was  brought  forward  three  years 
ago  as  a  substitute  for  quinine,  and  very  sanguine  expectations  of  its  thera- 
peutical utility  were  entertained.  Its  antipyretic  power  was  not  questioned, 
but  it  was  soon  perceived  that  certain  unpleasant,  even  dangerous  conditions 
were  induced  by  it.  Profound  depression,  severe  rigors,  profuse  sweats,  so 
often  occurred  when  its  antipyretic  powers  were  utilized,  that  very  soon  it 
ceased  to  be  employed,  and  the  safer  antipyretics  as  antipyrin,  acetanilide, 
salol,  etc.,  substituted. 

Prof.  Silvestrini  and  his  pupil  have,  however,  arrived  at  different  conclu- 
sions from  those  heretofore  held,  and  assert  that  it  has  an  immense  superiority 
over  its  cogeners,  in  its  perfect  innocuousness  in  the  strongest  doses.  It  is 
prompt  in  action,  and  the  higher  the  febrile  temperature,  the  more  powerful 
as  an  antipyretic.  In  typhoid,  acute  rheumatism,  and  erysipelas,  it  acts  in  a 
highly  efficient  manner;  and  besides  abating  the  temperature  of  fever,  it  has 
the  power  to  remove  the  attendant  symptoms — the  disturbances  of  pulse  and 
of  respiration,  the  elimination  of  urea,  the  blood  pressure,  etc. 

Hydroquinone  is  not  irritant,  and  any  gastro-intestinal  trouble  present  is 
not  increased  by  it.  Having  the  antiseptic  and  germicide  powers  belonging 
to  the  group,  when  introduced  into  the  intestinal  canal  it  arrests  the  process 
of  fermentation  by  inhibiting  the  microbes  necessary  to  the  process. 

The  dose  of  hydroquinone  ranges  from  five  to  thirty  grains,  the  frequency 
of  administration  determining  to  some  extent.  It  is  freely  soluble  in  water, 
and  unirritating,  and  hence  can  be  given  hypodermatically. 

Mercurial  Paralysis. 

An  elaborate  research,  pathological  and  clinical,  is  being  published,  on  the 
nature  and  site  of  mercurial  paralysis,  by  M.  Maurice  Letulle  in  the  Archives 
de  Physiologie,  Normale  et  Pathologique  for  1887.  This  study  is  in  continua- 
tion of  the  valuable  observations  of  Kiissmaul  and  those  of  Hallopeau,  and  is 
reinforced  by  the  large  field  of  clinical  investigation  furnished  by  the  great 
quicksilver  mines  of  Almaden. 

In  the  study  of  mercurial  trembling,  a  symptom  that  has  always  attracted 
much  attention,  our  author  finds  that  the  muscles  of  the  extremities  are  often 
feeble  although  trembling  has  not  occurred,  and  that  the  muscular  weakness 


MATEEIA   MEDIC  A   AND  THERAPEUTICS. 


527 


up  to  the  period  of  paralysis  is  not  accompanied  by  atrophic  degeneration. 
The  electrical  reactions,  when  the  paralysis  is  partial,  remain  normal.  The 
tendon  reflexes  do  not  disappear,  but  they  become  feeble.  Disorders  of  sen- 
sibility (dysesthesia)  accompany  the  other  phenomena — of  the  upper  ex- 
tremity constantly,  and  in  one-half,  only,  of  the  lower.  In  somewhat  more 
than  one-half  the  special  senses  were  affected,  and  were  bilateral.  The  pain 
experienced,  was  felt  in  the  areas  subsequently  paralyzed. 

Notwithstanding  appetite  and  digestion  remain  unimpaired,  loss  of  flesh 
goes  on  steadily;  degenerative  changes  having  many  of  the  characteristics  of 
senility  occur;  the  teeth  darken  and  become  even  black,  their  surface  rough- 
ened and  crossed  by  deep  lines  of  erosion,  and  grow  more  and  more  carious. 

As  regards  the  pathological  changes  in  the  nervous  system,  our  author  finds 
that  the  distinctive  characteristic  is  the  action  of  mercury  on  the  myeline; 
there  is  no  change  of  an  inflammatory  kind,  and  the  chemical  alteration  con- 
sists in  a  disintegration  and  disappearance  of  the  fatty  constituents  of  the 
nerve  elements. 

Methylal. 

Methyl  alcohol  is  the  source  of  the  new  local  anaesthetic.  It  is  neutral, 
volatile,  has  an  ethereal  odor,  and  a  pungent  taste.  An  investigation  of 
methylal  has  recently  been  made  by  Motrochin,  in  the  laboratory  of  Prof. 
Anreps  [Vratch,  No.  x.,  1887,  and  Bull.  Gen.  de  Th'erap.,  July  15,  1887). 
The  study  includes  observations  on  animals  and  on  man. 

The  inhalation  of  methylal  vapor  causes  drowsiness  and  sleep,  but  when 
the  inhalation  is  stopped,  the  sleep  ends.  During  the  time  of  its  action,  the 
sense  of  pain  is  abolished.  Respiration  is  slowed  somewhat,  but  also  deep- 
ened, and  there  is  no  alteration  of  its  rhythm.    The  heart  remains  unaffected. 

The  subcutaneous  injection  of  methylal  induces  more  or  less  anaesthesia, 
but  it  is  short  in  duration.  Reflex  action  is  lessened,  or  it  may  be  suspended 
entirely  if  a  sufficient  quantity  is  administered.  The  excitability  of  the 
psycho-motor  centres  is  much  diminished  when  the  remedy  is  injected  sub- 
cutaneously  or  inhaled,  but  this  effect  is  transient.  Methylal  antagonizes  to 
some  extent  the  actions  of  strychnine  and  picrotoxin. 

The  inhalation,  and  stomachal  administration,  are  by  far  better  modes  of 
giving  it  than  by  subcutaneous  injection.  It  acts  favorably  on  man,  and  in  a 
moderate  dose  produces  a  decided  anaesthesia,  especially  of  the  head  and  face, 
and  more  or  less  vertigo. 

It  is  obvious  from  these  facts  that  methylal  has  properties  and  powers  very 
similar  to  those  of  paraldehyde,  and  may  be  prescribed  in  all  morbid  states 
to  which  the  latter  has  been  considered  adapted. 

Action  of  Calomel  on  the  Bile. 

Dr.  J.  Zawadzky  (  Vratch,  1887,  quoted  by  the  Bull.  Gen.  de  Th'erap.,  July 
15,  1887)  presents  certain  conclusions  at  which  he  has  arrived  after  a  long, 
faithful,  and  conscientious  study  of  the  subject,  the  influence  of  calomel  on 
the  decomposition  of  the  bile. 

He  finds  that  calomel  has  the  property  to  prevent  the  decomposition  of  bile 
after  it  has  entered  the  duodenum.    The  characteristic  calomel  stools,  he  ex- 


528 


PROGKESS  OF   MEDICAL  SCIENCE. 


plains  by  the  transformation  of  bilirubine  into  biliverdine  in  the  presence  of 
Hg20  (corrosive  sublimate)  into  which  calomel  is,  in  part  at  least,  converted, 
after  entering  the  intestine.  From  this  point  of  view,  then,  the  so-called 
calomel  stools  are  not  the  result  of  a  cholagogue  action. 

Calomel  as  a  Diuretic. 

M.  Jendrassik  reports  (Deutsches  Archiv  fur  hlin.  Med.,  1886)  the  results 
obtained  from  the  combined  action  of  calomel  and  jalap — from  two  to  four 
grains,  of  each,  three  or  four  times  a  day.  From  the  second  to  the  fourth 
day  the  diuresis  begins,  and  is  very  active,  the  amount  of  urine  surpassing 
the  diuretic  action  of  digitalis.  The  quantity  of  urine  voided  increased  for 
several  days,  and  after  the  maximum,  gradually  lessens  to  the  normal.  By 
this  time  mercurial  salivation  has  occurred  to  some  extent,  but  less  than  if 
the  jalap  had  not  been  given.  It  is  asserted  by  Jendrassik  that  any  purgative 
action  lessens  the  diuretic. 

In  attempting  to  explain  the  action,  he  makes  no  mention  of  the  resin  of 
jalap,  which  is  a  stimulating  diuretic  of  considerable  power,  nor  does  he  refer 
to  the  reflex  influence  proceeding  from  the  intestine. 


MEDICINE. 


UNDER  THE  CHARGE  OF 

WILLIAM  OSLER,  M.D.,  F.E.C.P.  Lond., 

professor  of  clinical  medicine  in  the  university  of  pennsylvania. 
Assisted  by 

J.  P.  Crozer  Griffith,  M.D.,  Walter  Mendelson,  M.D., 

ASSISTANT  PHYSICIAN  TO  THE  HOSPITAL  OF  THE  INSTRUCTOR  IN  THE  LABORATORY  OF  THE  COLLEGE 

UNIVERSITY  OF  PENNSYLVANIA.  OF  PHYSICIANS  AND  SURGEONS,  NEW  YORK. 


The  Value  of  Sudoral  Eruptions  as  a  Prognostic  Sign  in  Typhoid. 

Lacaze  {Revue  de  Medecine,  1887,  p.  270),  after  a  definition  of  sudamina 
and  miliaria,  and  numerous  extracts  from  the  literature  of  the  subject,  con- 
cludes that  the  sudaminal  eruptions  which  appear  before  the  commencement 
of  the  second  week  of  typhoid  fever  have  no  value  in  determining  the  dura- 
tion or  the  prognosis  of  the  malady;  while  those  coming  after  the  second 
week,  during  the  doubtful  period,  are  almost  always  the  sign  of  the  com- 
mencement of  full  convalescence. 

On  a  Method  of  Prophylaxis  and  an  Investigation  into  the  Nature 
of  the  Contagion  of  Scarlet  Fever. 

Jamieson  and  Edington  (British  Medical  Journal,  1887,  1,  1262)  publish 
a  valuable  article  on  this  subject,  accompanied  by  a  colored  plate.  It  is 
acknowledged  that  scarlet  fever  is  but  little  communicable  in  its  early  stages, 
and  that  the  exhalations  from  the  mouth,  and  the  flakes  of  skin,  contain  the 


MEDICINE. 


529 


active  contagium.  Jamieson  has  previously  expressed  the  view  that  it  is 
probably  a  parasitic  organism,  and  that  when  inhaled  or  swallowed,  it  finally, 
in  the  course  of  the  disease,  reaches  the  skin  from  the  blood,  and,  ripening 
there,  is  ready  for  immediate  multiplication  in  the  body  of  some  other  indi- 
vidual. In  accordance  with  this  theory,  he  endeavored  to  prove  by  experi- 
ment that  it  is  possible  to  prevent  the  spread  of  the  disease  even  to  persons  in 
close  contact  with  the  patient.  For  this  purpose  he  made  frequent  applica- 
tions to  the  throat  of  a  strong  solution  of  borax  in  glycerine ;  while  to  disin- 
fect the  skin,  warm  baths  were  employed  every  night  from  the  beginning,  and 
a  mixture  of  carbolic  acid,  30  grains;  thymol,  10  grains;  vaseline,  1  drachm; 
simple  ointment,  2  ounces,  was  rubbed  over  the  entire  body  night  and  morn- 
ing.   In  this  way,  he  reasoned,  the  scales  would  never  become  contagious. 

The  experience  of  the  last  three  years  completely  bears  out  the  correctness 
of  this  opinion.  He  reports  a  series  of  cases  going  to  prove  that  the  treat- 
ment mentioned  decidedly  lessens  the  danger  of  the  spread  of  the  disease. 
He  also  quotes  some  cases  to  show  that  the  late  desquamation  contains  the 
contagium  in  the  largest  amount;  indicating  that  air  is  necessary  for  its 
maturation,  since  it  is  then  that  the  cuticle  is  more  fully  separated,  dried,  and 
oxygenated. 

The  following  lines  of  investigation  were  now  to  be  carried  out: 

1.  To  discover  the  organism  on  which  the  virulence  of  the  epithelial  flakes 
depends. 

2.  To  ascertain  at  what  period  it  first  appears. 

3.  To  determine  whether  the  clinical  methods  employed  as  described  for 
neutralizing  the  contagiousness  of  scarlet  fever  are  actually  capable  of 
killing  it. 

This,  the  bacterial  part  of  the  investigation,  was  carried  out  by  Edington. 
He  details  the  very  careful  methods  of  research  adopted,  with  the  numerous 
precautions  taken.  He  could  find  no  microbes  in  the  epithelial  scales  them- 
selves, and  it  is  probable  that  only  spores  are  to  be  found  here;  but  he 
describes  and  figures  several  species  of  bacilli  and  micrococci  obtained  in 
cultures  from  the  blood  and  scales.  Experiments  show,  however,  that  there 
is  but  one,  the  bacillus  scarlatince,  which  seems  to  be  truly  pathogenic.  This 
bacillus  is  4  n  in  thickness,  and  1.2  /z-1.4  fi  in  length;  motile,  and  occurring 
in  long,  jointed  filaments.  On  gelatine  plates  it  forms  points  of  liquefaction 
after  several  days.  It  rapidly  liquefies  Koch's  jelly  tubes,  but  with  no  distinct 
growth-formation,  and  develops  a  characteristic  pellicle  after  the  liquefaction 
is  well  advanced.  In  fluid  broth  it  forms  a  coherent,  parchment-like  pellicle 
within  four  hours,  which  later  exhibits  a  deep  wrinkling,  due  to  a  dense  net- 
work of  bacillary  filaments.  It  was  found  in  every  tube  but  one  (this  exception 
being  a  tube  broken  early  in  the  experiment),  if  started  after  the  end  of  the 
third  week,  but  never  before  this  time.  It  was  also  detected  in  every  culture 
tube  made  from  the  blood,  if  taken  before  the  third  day  of  the  fever.  When 
rabbits  are  inoculated  with  it,  it  produces  fever  and  an  erythema,  followed  by 
a  slight  desquamation ;  and  the  bacilli  can  be  reobtained  from  the  animal's 
blood.  The  effects  in  guinea-pigs  are  similar,  but  the  desquamation  is  more 
abundant,  and  the  flakes  thicker.  In  calves,  the  skin  of  the  thorax  becomes 
red,  and  an  erythema  develops;  there  is  fever,  and  later  desquamation. 

Regarding  the  third  question,  Edington  found  that  of  seven  cases  in  which 

NO.  CLXXXV11I. — OCTOBER,  1887.  34 


530 


PROGRESS   OF   MEDICAL  SCIENCE. 


the  treatment  had  been  continued  until  the  seventeenth  day,  the  part  being 
then  wrapped  in  sterilized  cotton-wool  until  the  thirtieth  day,  and  then 
examined  for  the  presence  of  bacilli,  none  were  present  in  five  cases,  and  the 
cultures  developed  very  slowly  in  the  other  two. 

It  seems  then  proven  that  the  bacillus  scarlatince  is  the  specific  cause  of 
scarlet  fever,  and  that  the  other  microbes  found  are  only  concomitants.  Yet 
one,  which  they  call  diplococcus  scarlatince  sanguinis,  occurs  very  frequently 
with  the  bacillus,  both  in  cultures  from  the  blood  and  from  the  epithelium. 
It  cannot  as  yet  be  definitely  settled  whether  it  modifies  in  any  way  the  action 
of  the  bacillus.  It  is  a  fact  that  both  organisms  were  found  from  the  first  in 
those  cases  which  exhibited  an  extremely  vivid  and  widespread  eruption. 

Hemiplegia  in  Children. 

Abercrombie  {British  Medical  Journal,  1887,  1,  3  323)  says,  that  while  all 
forms  of  paralysis  in  children  were  formerly  grouped  under  the  head  of 
essential  spinal  paralysis,  it  is  undoubtedly  true  that  very  many  cases  are  due 
to  a  cerebral  cause.  The  causes  of  hemiplegia  in  adults  are  hemorrhage, 
arterial  obstruction,  and  tumors ;  and  all  these  may  be  active  in  children. 
Cerebral  hemorrhage  in  infants  must  be  exceedingly  rare.  The  only  known 
causes  of  it  are  purpura  hemorrhagica,  the  hemorrhagic  diathesis,  and  aneu- 
risms of  the  cerebral  vessels ;  and,  in  a  few  instances,  a  highly  vascular  sar- 
coma has  given  rise  to  a  large  extravasation  of  blood.  Meningeal  and  capillary 
hemorrhages  may  also  occur,  and  it  is  conceivable  that  whooping-cough  might 
also  produce  massive  hemorrhage,  though  the  author  has  never  seen  a  case. 
Arterial  obstruction  from  embolism  due  to  heart  disease,  is  occasionally  met 
with,  and  it  is  strange  that  it  is  not  oftener  seen.  Thrombosis  may  take  place, 
brought  about  by  previously  existing  disease  of  the  vessels ;  syphilis  probably 
causing  hemiplegia  in  this  way.  Tumors  are  not  uncommon,  usually  in  the 
pons  or  crus.  It  must  be  also  mentioned  that  tubercular  meningitis  not  unfre- 
quently  produces  unilateral  paralysis. 

But  the  author  has  observed  some  fifty  cases  of  hemiplegia  in  children,  only 
a  few  of  which  could  be  accounted  for  by  any  of  the  causes  mentioned.  The 
others  may  be  divided  into  two  groups — those  which  followed  one  of  the  acute 
infectious  diseases,  and  a  much  larger  group  where  no  such  cause  could  be 
assigned.  In  the  first  group  hemiplegia  oftenest  succeeded  diphtheria  in  the 
author's  experience,  though  he  has  also  seen  it  four  times  after  measles,  once 
after  whooping-cough,  and  once  after  scarlet  fever.  In  the  second  group  there 
was  evidence  of  congenital  syphilis  in  four  patients,  and  the  other  cases  fall 
naturally  into  three  classes,^  e. — (a)  traumatic;  (b)  congenital;  (c)  neither 
traumatic  nor  congenital,  nor  due  to  any  of  the  causes  already  described. 

Traumatism  during  labor  has  undoubtedly  been  the  cause  of  hemiplegia  in 
some  instances,  but  the  author  has  seen  only  one  case  which  was  probably 
due  to  injury — that  of  a  child  who  had  fallen  upon  his  head.  He  has  also 
seen  only  four  cases  in  which  the  paralysis  could  be  called  congenital.  The 
last  class  of  cases  can  only  be  subdivided  into  those  occurring  under  two 
years  of  age,  and  those  developing  after  that  age.  The  first  subdivision  con- 
tains essentially  the  cases  of  infantile  cerebral  paralysis,  and  the  author  has 
the  notes  of  fourteen  of  them,  ten  of  which  were  in  girls.    The  intellect  was 


MEDICINE. 


531 


usually  much  below  par.  In  the  second  subdivision  he  has  seen  but  four 
cases,  two  of  them  after  epilepsy. 

To  sum  up  briefly  the  symptoms  of  hemiplegia  in  children :  it  usually  attacks 
those  under  one  year  of  age,  commencing  with  a  prolonged  convulsion  lasting 
hours  or  days.  When  the  fit  passes,  the  child  is  found  to  have  lost  its  reason 
or  speech,  or  both,  and  to  be  paralyzed  on  one  side.  Sensation  is  rarely 
affected ;  a  little  improvement  may  follow,  especially  in  the  leg.  The  paralysis 
may  come  on  after  one  of  the  acute  infectious  diseases,  or  as  a  result  of  syphilis, 
but  often  no  cause  can  be  found. 

The  pathological  conditions  present  are  nearly  always  the  same,  viz.,  a 
sclerosis  and  atrophy  of  the  convolutions  in  the  motor  area  of  the  affected 
hemisphere,  with  thickening  and  opacity  of  the  meninges.  Various  theories 
have  been  held  concerning  the  production  of  the  disease.  Striimpell  believes 
the  cause  to  be  polio-encephalitis,  but  this  view  demands  further  proof.  The 
occurrence  of  capillary  hemorrhage  is  advocated  by  Eustace  Smith;  while 
Goodhart  believes  that  the  convulsions  produce  cerebral  congestion  and  then 
meningeal  hemorrhage  which  gives  rise  to  the  paralysis.  But  the  objection 
to  these  theories  of  hemorrhage  is,  that  there  should  be  no  tendency  for  the 
effusion  of  blood  to  affect  one  part  of  the  brain  more  than  another,  and  the 
lesion  in  this  disease  is  localized.  Gower's  theory  is  that  it  is  due  to  throm- 
bosis of  the  veins  and  sinuses  occurring  in  debilitated  conditions,  or  after 
blows  on  the  head ;  while  Goodhart  admits  that  embolism  is  the  probable 
cause  after  the  exanthemata.  The  author  believes  that  embolism  is  the  prin- 
cipal cause  of  hemiplegia  in  children.  The  autopsies  of  some  of  his  cases 
prove  this,  and  he  sees  nothing  in  the  symptoms  of  the  other  cases  following 
the  exanthemata  incompatible  with  this  view.  In  the  syphilitic  cases,  too, 
the  cause  may  have  easily  been  arterial  obstruction  from  the  thickening  of 
the  vessels  by  disease;  and  the  identity  of  the  symptoms  in  the  remaining  cases 
renders  the  presence  of  arterial  obstruction  a  probable  explanation  of  them 
also.  Moreover,  the  limitation  of  the  lesion  chiefly  to  the  region  supplied  by 
the  middle  cerebral  artery  is  another  argument  for  the  causal  agency  of  em- 
bolism. In  the  congenital  cases  the  pathological  conditions  are  often  more 
extreme  than  in  the  acquired  forms.  Frequently  entire  portions  of  the  brain 
are  wanting. 

The  diagnosis  of  the  disease  from  infantile  spinal  paralysis  is  easy,  from  the 
fact  that  it  is  unilateral,  and  that  the  affected  limbs  are  not  flaccid,  wasted,  or 
cold,  as  in  the  latter  disease. 

The  prognosis,  quoad  vitam,  is  good.  The  leg  usually  improves  consider- 
ably ;  the  arm  to  a  less  degree. 

The  treatment  during  the  convulsion  must  be  by  warm  or  cold  baths,  as 
indicated  by  the  bodily  temperature.  All  possible  sources  of  reflex  irritation 
must  be  sought  after  and  removed.  A  blister  behind  the  ears  of  the  side 
opposite  that  of  the  convulsed  limbs  would  do  no  harm.  Bleeding  should  be 
avoided,  unless,  perhaps,  in  a  traumatic  case  where  meningitis  is  suspected. 
After  the  convulsion  a  course  of  potassium  iodide  and  alkalies,  with  faradi- 
zation, may  be  commenced.   

Periodic  Paralysis. 

Cousot  [Rev.  de  Med.,  1887,  No.  3,  p.  190)  gives  a  detailed  account  of  five 
cases  of  periodic  paralysis,  and  adds  the  notes  of  four  others  gathered  from 


532 


PROGRESS  OF   MEDICAL  SCIENCE. 


the  literature.  Two  of  these,  published  by  Westphal  and  Hartwig  respectively, 
can  be  classified  with  his  own  ;  but  the  others  seem  to  be  of  an  entirely  differ- 
ent nature,  and  probably  belong  to  the  class  of  paralyses  due  to  malaria,  which 
are  quite  distinct  from  the  genuine  periodic  spinal  paralysis,  according  to  the 
author's  definition. 

The  affection  consists  in  attacks  of  paralysis  occurring  at  intervals  variable 
for  different  cases,  though  usually  showing  some  regularity  in  any  given 
case.  They  may  appear  daily,  every  few  days,  every  week,  etc.  The 
degree  of  the  paralysis  varies  even  in  the  same  person,  sometimes  being 
slight,  sometimes  absolute.  The  extent  also  varies  in  a  similar  manner,  and 
at  times  even  speech  and  respiration  are  partially  involved.  The  attacks, 
which  often  occur  in  the  night,  are  preceded  by  weakness  in  the  joints,  tingling, 
muscular  pain,  thirst,  and  perspiration.  The  paralysis  then  develops  more  or 
less  rapidly,  reaches  a  maximum  lasting  a  variable  time,  and  disappears  by 
degrees.  The  total  duration  of  the  attacks  varied  in  the  author's  cases  from 
three  to  thirteen  hours.  The  temperature  is  normal,  the  pulse  but  slightly,  if 
at  all,  affected,  and  sensation  and  intelligence  undisturbed.  Profuse  perspi- 
ration often  attends  or  follows  the  paralysis.  After  the  attack  the  muscles 
fully  regain  their  power,  and  the  general  health  is  seen  to  be  unimpaired.  A 
most  characteristic  symptom  is  the  temporary  diminution  or  complete  sup- 
pression of  the  electrical  excitability  in  the  paralyzed  muscles,  without  any 
trace  of  the  reaction  of  degeneration. 

Concerning  the  cause  and  nature  of  the  malady,  no  predisposing  influence 
could  be  detected  in  any  of  the  cases,  and  there  was  no  history  of  malaria. 
The  disease  appeared  in  most  cases  in  youth,  and  was  of  indefinite  duration. 
In  one  case  it  disappeared  permanently  after  childbirth,  and  in  another  lasted 
through  life.  Heredity  seems  to  play  some  part  in  its  production,  as  all  of 
the  author's  cases  were  members  of  one  family. 

There  appears  to  be  no  other  disease  with  which  it  can  be  easily  confounded, 
or  to  whose  domain  it  can  be  assigned.  The  author  believes  the  paralysis  to 
be  one  of  inhibition,  but  whether  the  point  of  departure  is  peripheral  or  central 
cannot  be  decided. 

Landry's  Paralysis. 

No  advances  have  been  made  in  the  study  of  this  disease  since  it  was  first 
described,  while  many  cases  of  other  disorders  have  undoubtedly  been  pub- 
lished as  instances  of  it.  MAisnsr  {Med.  Chron.,  1887,  vi.  99)  reports  a  case 
coming  under  his  observation.  The  patient,  aged  forty-eight,  without  syphi- 
litic or  neurotic  taint,  was  attacked  by  a  sensation  of  cold  and  tingling  in  his 
toes  and  feet,  accompanied  by  cramp-like  pain,  which  soon  disappeared. 
Diminution  of  power  in  the  legs  and  feet  rapidly  developed,  so  that  in  less 
than  a  week  he  was  totally  unable  to  walk,  although  he  could  still  move  his 
legs.  At  the  end  of  a  week  from  the  onset  of  the  disease  the  legs  and  trunk 
were  absolutely  paralyzed,  and  the  arms  involved  to  a  great  extent.  Sensa- 
tion was  unaffected ;  there  was  no  pain  or  tenderness;  no  spasm;  no  fever. 
The  electrical  reactions,  both  qualitative  and  quantitative,  were  normal ;  the 
reflexes  were  everywhere  abolished;  mastication,  deglutition,  and  respiration 
were  undisturbed.  A  large  amount  of  albumen  was  found  in  the  urine.  On 
the  next  day  the  arms  were  totally  paralyzed,  and  some  embarrassment  of 


MEDICINE. 


533 


respiration  was  observed.  This  latter  symptom  became  better,  but  returned 
on  the  same  day,  and  the  patient  died  apparently  from  asphyxia,  with  the 
intellect  clear. 

At  the  autopsy  no  lesion  could  be  found  anywhere  in  the  nervous  system, 
nor  did  the  muscles  reveal  any  change.  The  liver  was  swollen  and  filled 
with  blood  ;  the  kidneys  deeply  congested. 

This  case  is  an  instance  of  typical  Landry's  paralysis.  Viewed  from  a 
clinical  standpoint  it  could  not  have  been  acute  disease  of  the  anterior  cornua, 
on  account  of  the  absence  of  fever,  the  continuously  progressive  spread  of  the 
paralysis,  and  the  character  of  the  electrical  reactions.  It  ran  too  rapid  a  course 
for  us  to  take  muscular  atrophy  into  account.  Multiple  neuritis  would  have 
exhibited  pain,  tenderness,  ansesthesia,  and  altered  electrical  relations.  Mye- 
litis and  meningeal  hemorrhage  are  excluded  by  absence  of  sensory  and  trophic 
disturbance,  and  of  pain  in  the  back  and  spasm  respectively.  We  are  limited 
then  to  one  of  two  inferences;  either  there  was  some  lesion  of  the  gray  matter 
too  fine  to  be  detected  by  our  methods  of  research,  or  some  toxic  influence 
was  at  work.  The  first  hypothesis  cannot  be  entertained  in  the  presence  of  a 
paralysis  so  widespread  as  this.  We  must  then  accept  the  second,  that  by 
some  selective  toxic  agency  the  nerve  molecules  in  some  part  of  the  motor 
tract  were  deprived  of  their  potential  energy.  This  was  the  view  of  Landry, 
Westphal,  and  others. 

Two  questions  now  arise :  first,  as  to  the  nature  and  origin  of  the  poison ; 
and,  second,  on  what  part  of  the  motor  tract  does  it  act.  It  is  more  than 
probable  that  substances  closely  resembling  the  cadaveric  alkaloids  maybe 
formed  in  the  body  during  life,  under  the  influence  of  certain  morbid  pro- 
cesses ;  and  this  without  the  intervention  of  microorganisms.  These  sub- 
stances may  act  poisonously  on  the  nervous  system,  just  as  we  see  many  of 
the  vegetable  alkaloids  exercising  a  selective  power  as  to  the  part  of  the 
nervous  tissue  attacked.  The  author  examined  the  blood  for  ptomaines  after 
the  patient's  death,  but  failed  to  find  any.  This,  however,  is  no  proof  of  the 
absence  of  the  poison,  since  great  difficulties  attend  the  investigation,  and 
many  of  the  alkaloids  of  this  class  are  very  unstable. 

The  second  question,  regarding  the  localization  of  the  inhibitory  influence, 
is  a  matter  of  inference  only.  It  seems  most  likely  that  it  is  exerted  on  the 
gray  matter  of  the  anterior  cornua,  at  the  termination  of  the  upper  segment  of 
the  spinal  motor  path,  not  on  the  ganglionic  cells.  Why  the  paralysis  almost 
invariably  appears  in  the  lower  extremities  first  is  difficult  to  understand ;  but 
the  author  attempts  to  explain  it  on  the  ground  that  the  assumed  toxic  agency 
interferes  with  the  conduction  of  the  mctor  impulses  from  the  cortex  through 
the  cord,  and  these  consequently  first  fail  to  reach  the  more  distant  lower 
extremities,  since  the  absorption  of  energy  is  proportionate  to  the  amount  of 
inhibited  tissue  through  which  the  motor  impulses  must  pass.  It  is  on  this 
account  that  the  invasion  of  the  disease  is  almost  imperceptible ;  but  as  the 
inhibitory  influence  increases  in  power  the  paralysis  travels  upward. 

The  absence  of  bulbar  symptoms  was  a  peculiar  feature  in  the  author's 
case,  and  one  not  easily  explained. 


534 


PROGRESS   OF   MEDICAL  SCIENCE. 


The  Hereditary  Chorea  of  Adults  (Huntington's  Chorea). 

Huber  (  Virchow's  Archiv,  Bd.  cviii.  H.  2,  267-286)  reports  a  series  of  cases 
of  this  excessively  rare  disease.  According  to  the  definition  of  Huntington, 
who  first  described  it,  hereditary  chorea  is  characterized  as  follows  :  1.  It  is 
inheritable,  and  there  are  whole  families  afflicted  by  it.  If  a  generation  once 
escapes,  the  power  of  the  disease  is  lost,  and  it  does  not  appear  in  the  family 
again.  2.  It  begins  as  an  ordinary  chorea,  increases  to  the  greatest  degree, 
often  leads  to  mental  derangement  with  suicidal  impulse,  and  finally  ends  in 
death.  No  case  of  recovery  has  been  observed.  3.  It  begins  usually  between 
the  ages  of  thirty  and  forty  years ;  seldom  beyond  this,  and  never  in  youth. 

The  first  case  was  that  of  a  man  seen  in  the  Zurich  clinic  in  1886.  He  was 
thirty-eight  years  of  age,  and  exhibited  choreic  movements  of  great  intensity 
and  extent,  perfectly  incoordinated,  and  almost  universal,  although  not  nearly- 
so  violent  in  the  legs  as  in  the  arms  and  head.  Even  the  tongue  and  the  soft 
palate  frequently  underwent  involuntary  movements.  There  was  no  evidence 
of  paralysis  anywhere,  or  of  any  alteration  of  sensation  ;  and  the  electrical 
reaction  and  the  reflexes  were  normal.  The  speech  was  interrupted,  slightly 
nasal,  and  indistinct,  as  though  the  patient  had  something  in  his  mouth. 
Prescribed  movements  with  the  arms  and  .hands  were  performed  with  sur- 
prising certainty,  and  the  choreic  motions  almost  disappeared  for  the  time ; 
the  handwriting,  however,  showed  that  voluntary  control  over  the  hands  was 
not  complete.  He  walked  with  difficulty.  The  disease  began  eight  years 
ago  with  twitching  of  the  eyelids,  then  of  the  mouth,  and  within  a  year,  of 
the  shoulders,  head,  and  arms.  For  the  first  six  years  there  was  scarcely  any 
disturbance  of  motion  in  the  legs ;  and  six  months  ago  he  could  speak  per- 
fectly well.  On  investigation  it  was  found  that  the  sister,  father,  two  pater- 
nal uncles,  and  an  aunt,  and  the  paternal  grandfather  and  great-grandfather 
were  affected  by  the  same  disease.  In  another  branch  of  the  family,  descended 
from  this  same  great-grandfather,  there  was  a  second  cousin  of  the  patient, 
together  with  his  father,  who  suffered  from  chorea,  developing  late  in  life.  The 
author  was  unable  to  learn  anything  regarding  the  mother  of  this  father  last 
mentioned  (i.  e.,  the  daughter  of  the  choreic  great-grandparent),  but  it  is  cer- 
tainly possible  that  she  had  chorea ;  and  the  law  of  Huntington  concerning 
heredity  is  therefore  not  broken.  In  that  branch  of  the  family  the  disease  was 
not  so  pronounced  as  in  the  case  described ;  but  in  the  sister  of  this  patient 
— whom,  also,  the  author  was  fortunate  enough  to  see — it  was  very  typical. 
Here  the  patient,  aged  forty-two,  had  commenced  thirteen  years  before  to  be 
somewhat  slow  both  in  body  and  mind,  forgetful,  and  listless.  After  six  years, 
choreic  movements  began  in  the  shoulders,  and  in  two  years  became  almost 
universal,  while  some  affection  of  the  speech  had  developed.  When  examined 
in  1886,  she  exhibited  even  more  pronounced  movements  than  her  brother  ; 
her  face  had  a  rather  stupid  expression,  and  she  was  totally  unable  to  speak  ; 
she  could  not  extrrdethe  tongue,  and  this  organ  wras  decidedly  hypertrophied 
and  was  in  continual  motion.  In  this  case,  too,  intended  movements  were  per- 
formed very  well,  and  the  chorea  diminished  temporarily.  The  legs  were 
much  less  affected  than  the  arms.  The  patient  died  later.  Her  daughter  was 
below  average  intelligence,  but  was  only  ten  years  of  age  and  chorea  had  not 
yet  developed. 


MEDICINE. 


535 


Huber  was  able  to  learn  of  the  father  that  he  had  died  in  an  asylum,  the 
diagnosis  being  chorea  and  imbecility.  His  disease  began  in  his  forty-fifth 
year  with  choreic  motions,  which  gradually  grew  worse,  and  were  associated 
with  unintelligible  speech  and  increasing  weakness  of  intellect.  At  times  he 
suffered  from  attacks  of  mania  resembling  those  of  epilepsy.  Toward  the 
end  of  life  the  imbecility  became  extreme,  and  the  movements  almost  ceased. 

He  thinks  the  name  chorea  must  certainly  be  applied  to  these  cases,  although 
the  two  which  he  himself  observed  differed  in  some  respects  from  the  ordinary 
form,  especially  in  that  with  intended  movements  the  choreic  became  very 
slight  or  even  ceased.  And  in  all  the  cases  included  in  this  report  the  dis- 
ease first  manifested  itself  in  adult  life.  It  could  not  be  learned  that  the 
chorea  of  childhood  had  ever  occurred  in  the  family. 

The  Pathogenesis  and  Treatment  of  Diabetic  Coma. 

Lepine  {Rev.  de  Med.,  No.  3,  224)  does  not  believe  that  either  acetone  or 
diacetic  acid  is  the  cause  of  the  coma  occurring  in  the  course  of  diabetes,  but 
considers  it  due  to  lessened  alkalinity  of  the  blood.  Stadelmann  determined 
that  there  was  an  acid  actually  produced  in  diabetes,  by  which  the  blood's 
alkalinity  was  diminished.  This  he  found  in  the  urine  and  believed  to  be 
crotonic  acid,  although  later  researches  by  others  have  shown  it  to  be  /3-oxy- 
butyric  acid.  He,  therefore,  treated  his  cases  with  large  doses  of  bicarbonate  of 
soda,  administering  even  as  much  as  100  grm.  per  diem.  If  coma  had  already 
developed,  he  recommended  large  intravenous  injections.  Although  Wolpe 
followed  this  plan  of  treatment  without  success,  Lepine  attempted  it  in  one 
instance,  and  reports  the  details  of  his  experiment.  In  a  very  severe  case  of 
diabetes,  in  which  coma  had  already  developed  with  a  temperature  of  96°  F., 
he  injected  into  the  median  cephalic  vein  1.5  litres  of  water  at  104°  contain- 
ing 8  grm.  of  sodium  chloride  and  34  grm.  of  sodium  bicarbonate.  The  tem- 
perature immediately  rose  to  97.5°  and  the  coma  became  less  profound. 
Twelve  hours  later  he  administered  a  second  injection,  just  before  which  the 
blood  was  found  to  be  nearly  neutral,  and  shortly  after  which  the  urine  was 
very  decidedly  acid  but  contained  no  glucose.  Again  there  was  temporary 
improvement,  but  the  patient  died  some  hours  later.  From  the  condition  of 
the  urine  and  the  blood  it  is  evident  that  some  acid  existed  in  the  economy 
capable  of  neutralizing  an  enormous  quantity  of  alkali.  Lepine  does  not 
think  that  the  combination  of  this  acid  with  a  base  is  the  object  to  be  attained 
in  giving  alkaline  injections,  for  the  salts  produced  are  also  poisonous.  The 
introduction  of  soda  into  the  economy  acts  rather  as  favoring  the  destruction 
and  elimination  of  the  poisonous  acid.  We  should,  therefore,  begin  the  treat- 
ment as  early  as  possible  in  grave  cases,  in  order  to  prevent  the  formation  of 
the  acid.  An  exclusive  diet  of  meat  is  to  be  avoided  in  diabetes,  since  it  is 
in  cases  receiving  this  diet  that  coma  is  especially  liable  to  develop. 

Contribution  to  the  Diabetic  Dyscrasia. 

In  connection  with  the  article  just  mentioned,  that  by  Hugounenq  [Rev. 
de  M'ed.,  1887,  p.  30)  is  of  interest.  This  author  had  the  opportunity  of  studying 
a  case  dying  with  diabetic  coma.  He  examined — 1.  The  urine  of  the  patient 
before  any  treatment  was  instituted.    2.  The  blood  ;  drawn  before  a  solution 


536 


PROGKESS  OF   MEDICAL  SCIENCE. 


of  forty-four  grains  of  bicarbonate  of  soda  was  injected  into  the  veins.  3. 
The  urine  after  this  injection.  In  the  first  specimen  he  found  /3-oxybutyric 
acid  in  addition  to  sugar.  In  the  second  specimen,  the  blood,  he  found  the 
same  acid.  The  third  specimen  contained  neither  the  acid  nor  sugar.  In  an 
effort  to  explain  these  facts  the  author  takes  up  the  chemical  relationship  of 
glucose  to  some  of  its  derivatives.  /3-oxybutyric  acid  is  the  homologous 
superior  of  lactic  acid  of  the  muscles.  Its  formation  at  the  expense  of  dis- 
eased tissue  is  no  more  remarkable,  then,  than  the  production  of  the  latter 
acid  in  the  wearied  muscle.  Diacetic  acid  is  but  a  further  oxidation,  and  is, 
in  fact,  found  in  the  urine  with  /3-oxybutyric  acid.  Diacetic  acid  is,  how- 
ever, very  unstable,  and  readily  changes  into  acetone,  the  last  of  the  series. 
By  just  what  process  in  the  living  body  sugar  is  converted  into  /?-oxybutyric 
acid,  and  thus  the  chain  from  glucose  to  acetone  completed,  is  not  under- 
stood. Outside  of  the  body  there  is  a  simple  method  by  which  the  change 
may  be  brought  about;  the  glucose  becoming  alcohol,  aldehyde,  and  then 
aldol,  before  it  reaches  the  condition  of  /3-oxybutyric  acid.  The  same  result 
is  certainly  attained  ultimately  in  the  body,  whatever  the  method  may  be. 

These  studies  show  us  how,  in  the  diabetic  dyscrasia,  glucose  or  the  various 
compounds  derived  from  it,  leave  the  body  before  being  completely  consumed 
into  water  and  carbonic  dioxide,  as  is  the  case  in  health.  Thus  the  organism 
loses  the  heat  of  their  combustion  ;  a  part  of  the  chemical  energy  from  which 
it  draws  its  strength.  Eational  therapeutics  teaches  us  then  to  attempt  to 
consume  these  substances  in  the  economy.  As  the  reaction  described  proves, 
this  can  be  very  well  accomplished  by  means  of  alkali,  and  this  plan  of  treat- 
ment should  not  be  neglected. 

Parenchymatous  Myositis. 

Several  interesting  accounts  of  cases  of  this  little  known  disease  have  re- 
cently appeared  in  the  German  medical  press.  Hepp  {Berliner  Min.  Wochen- 
schrift,  1887,  No.  17,  297,  and  No.  18,  322)  reports  a  form  of  acute  parenchy- 
matous myositis  which  he  entitles  "  Pseudo-trichinosis."  It  is  an  exceedingly 
rare  affection,  and  but  two  cases,  he  states,  are  to  be  found  in  the  literature 
which  can  be  classified  with  it.  It  consists  of  an  acute  parenchymatous  in- 
flammation of  nearly  all  the  skeletal  muscles;  seeming  to  be  an  independent 
disease,  but  probably  of  an  infectious  nature,  although  no  cause  can  be  found 
for  it.  It  presents  in  its  symptoms  the  greatest  similarity  to  trichinosis,  and 
may,  like  it,  cause  death. 

The  case  in  question  was  that  of  a  woman,  aged  thirty-six,  who  after  feeling 
not  quite  well  for  some  weeks,  was  suddenly  attacked  by  angina  and  an  exan- 
them.  Both  disappeared  soon,  but  eight  days  later  progressively  increasing 
pain,  swelling,  and  stiffness  of  the  muscles  developed.  When  admitted  to  the 
hospital  about  two  months  after  the  first  symptoms  had  made  their  appear- 
ance, she  lay  helpless  on  her  back  in  bed.  The  face  about  the  eyelids,  and 
the  limbs  except  the  hands  and  feet,  exhibited  a  peculiar  hard  oedema  which 
pitted  with  difficulty,  and  which  transformed  the  arms  into  firm,  cylindrical, 
swollen  masses.  The  affected  muscles  everywhere  were  in  a  permanently  stiff, 
contracted  condition,  without  elasticity.  There  was  no  tenderness  or  pain 
when  at  rest  or  on  limited  passive  motion,  but  more  extended  movement 


MEDICINE. 


537 


caused  great  suffering.  The  patient  was  unable  to  lift  her  head  from  the 
pillow,  and  could  scarcely  move  her  arms ;  while  her  legs  were  in  not  much 
better  condition.  The  fingers,  feet,  and  toes  could,  however,  be  moved  with 
ease.  The  muscles  of  the  face  did  not  appear  to  be  involved,  and  the  joints 
everywhere  were  unaffected;  the  tendon  reflexes  were  abolished,  and  the 
electrical  excitability  diminished.  None  of  the  inner  organs  gave  evidence 
of  disease,  but  the  urine  contained  considerable  albumen. 

Her  condition  while  in  the  hospital  grew  steadily  worse.  Cramp-like  pain, 
increased  swelling  of  the  skin,  still  less  power  of  motion,  a  nasal  voice,  cough 
with  great  difficulty  in  expectoration,  trouble  in  swallowing,  and  great  ten- 
derness and  hyperesthesia  were  noticed ;  there  was  more  or  less  fever,  and 
much  weakness.  The  difficulty  in  swallowing  grew  worse,  and  attacks  of 
suffocation  intervened,  in  one  of  which  she  died,  eleven  days  after  admission 
and  in  the  eleventh  week  of  the  disease. 

The  autopsy  revealed  a  widespread  degeneration  of  all  the  striated  muscles 
except  the  heart,  diaphragm,  and  the  muscles  of  the  orbit.  Macroscopically 
they  were  pale,  yellowish,  saturated  with  fluid,  easily  torn,  and  resembling  in 
appearance  the  flesh  of  rabbits  or  fish.  Microscopically  a  hyaline  degenera- 
tion became  visible,  having  produced  in  some  places  entire  destruction  of  the 
contractile  substance.  There  was  virtually  no  small-celled  infiltration,  and 
the  process  had  evidently  taken  place  in  the  muscle  fibre  itself.  There  was 
no  fatty  or  granular  degeneration,  as  in  trichinosis. 

The  author  feels  justified  in  calling  this  a  case  of  acute  parenchymatous 
myositis.  The  disease  may  be  distinguished  from  multiple  neuritis  by  the 
limitation  of  the  pain  to  the  muscles,  their  peculiar  consistence  and  stiffness, 
and  the  unusual  hardness  of  the  oedema.  (Edema  of  this  type  is  met  with  in 
different  varieties  of  myositis,  as  the  syphilitic,  rheumatic,  ossifying,  ischemic; 
sometimes  in  myositis  attending  the  acute  infectious  diseases,  including 
tetanus;  and  in  trichinosis.  It  is  of  an  inflammatory  nature,  while  that  seen 
in  neuropathic  paralysis  is  vasomotor  in  origin,  and  is  not  so  hard ;  nor  is  it 
limited  to  districts  of  inflamed  muscle.  Even  from  a  purely  clinical  point  of 
view  this  case  could  not  have  been  trichinosis,  for  no  trichinous  flesh  had 
been  eaten,  there  had  been  no  gastro-enteric  symptoms,  and  the  diaphragm 
and  muscle  of  the  eye  were  not  involved.  The  angina  at  the  outset  suggested 
myositis  following  diphtheria.  But  there  had  existed  no  diphtheria  in  the 
family,  and  such  a  process,  dependent  on  this  disease,  has  never  been  ob- 
served. 

The  author  then  describes  the  two  cases  in  the  literature  to  which  he  had 
referred.  They  were  reported  by  Potain  and  Marchand  respectively,  and 
both  ended  fatally.  He  claims  that  they  were  almost  identical  in  their  symp- 
toms with  his  case,  and  must  be  classified  with  it. 

In  a  later  publication  {Ibid.,  1887,  No.  22,  380)  the  same  author  describes  a 
case  of  severe  parenchymatous  inflammation  of  circumscribed  muscle  masses 
of  the  right  gluteal  region  and  the  right  upper  arm,  leading  to  amyloid  de- 
generation with  the  production  of  fluctuating  swellings  without  pus,  and 
accompanied  by  hard,  circumscribed  oedema  of  the  skin.  The  patient,  a 
man  of  twenty-one  years,  fell  in  a  violent  epileptic  fit,  biting  his  tongue 
severely.  Weakness  and  pain  produced  repeated  falls  on  the  same  day,  and 
he  probably  bruised  his  muscles  considerably.    His  tongue  became  swollen 


538 


PROGRESS  OF   MEDICAL  SCIENCE. 


and  partly  covered  with  a  diphtheritic  deposit;  and  the  author  believes  that 
through  some  infection  from  this  source  the  severe  parenchymatous  inflam- 
mation of  the  muscles  was  produced,  instead  of  the  suppurative  process  which 
might  have  ordinarily  followed  the  bruising. 

Hepp  refers  to  interesting  cases  reported  by  Kreiss,  Giess,  and  Wagner. 
Those  of  the  two  former  were  likewise  instances  of  localized  parenchymatous 
myositis,  but  that  of  the  latter  must  be  classified  with  Hepp's  first  case. 

Wagner's  case  (A  Case  of  Acute  Polymyositis  Deutsches  Archiv,  Bd.  xl.,  H. 
3-4,  241)  was  that  of  a  woman,  aged  thirty-four,  presenting  the  symptoms  of 
tuberculosis  of  the  left  apex.  She  complained  also  of  some  pain  and  stiff- 
ness in  the  back,  loins,  neck,  shoulders,  and  joints  of  the  hands,  together 
with  some  oedema.  There  was  no  history  of  taking  cold.  Later  both  arms 
became  much  swollen,  the  contour  of  the  muscles  disappeared,  there  was  no 
pitting  or  tenderness  on  pressure.  The  swelling  gradually  diminished  some- 
what, and  became  much  softer.  There  was  no  tenderness  over  the  nerve 
trunks,  disturbances  of  sensation  were  nowhere  marked,  and  the  electrical  re- 
actions were  always  normal.  The  cough  gradually  grew  worse,  and  attacks  of 
suffocation  on  attempting  to  swallow  made  their  appearance,  which  did  not 
seem  to  be  commensurate  with  the  slight  degree  of  the  tuberculous  process. 
In  one  of  these  attacks  she  died,  having  been  under  observation  two  months. 

The  diagnosis  had  presented  some  difficulties.  No  obstruction  to  the  cir- 
culation could  be  found.  The  painlessness  of  the  nerve  trunks  with  the 
normal  electrical  reactions  excluded  neuritis.  The  presence  of  rheumatism 
was  possible;  but  the  greatest  likeness  was  to  trichinosis,  although  the  free- 
dom from  involvement  of  the  legs  and  face  excluded  that  disease.  The 
.autopsy  revealed  an  extensive  disease  of  the  muscles  throughout  the  body. 
Those  of  the  arms  were  pale  red,  of  a  peculiarly  stiff  consistence,  of  a  rather 
homogeneous  appearance,  saturated  with  serum  and  easily  separable  into 
fibres.  Nearly  all  the  muscles  of  the  upper  half  of  the  body,  including  the 
intercostals  and  diaphragm,  were  more  or  less  affected,  either  throughout  or 
in  spots.  There  was  no  affection  of  the  joints.  Microscopically  both  fatty 
and  amyloid  degenerations  of  the  muscles  were  found.  A  small-celled  infil- 
tration was  seen  in  parts,  and  a  partial  reformation  of  the  fibres.  The 
author  gives  a  detailed  description  of  the  microscopical  appearance,  accom- 
panied by  several  woodcuts. 

He  reviews  carefully  the  various  published  cases  which  seem  to  him  to 
resemble  his  in  any  particular,  and  concludes  that  his  case  was  one  of  the 
most  acute  forms  of  progressive  muscular  atrophy,  adducing  at  length  his 
reasons  for  this  belief. 

Extreme  Frequency  of  the  Pulse  after  Paracentesis. 

Dehio  {St.  Petersb.  Med.  Wochensch.,  quoted  in  Lancet,  1887, 1, 1098)  reports 
■an  interesting  case  of  paracentesis  for  ascites  in  cirrhosis  of  the  liver.  The 
pulse  had  been  86,  regular,  and  of  moderate  tension.  No  heart  disease  could 
be  detected.  On  the  day  after  the  operation  the  pulse  was  162  and  thready, 
and  the  patient  was  pale,  and  complained  of  dizziness  and  prostration.  After 
five  days  of  rapid  pulse  0.002  grm.  coronilin  was  given  subcutaneously,  fol- 


MEDICINE. 


539 


lowed  by  a  reduction  of  the  pulse  to  80  for  a  few  hours  only,  after  which  it 
rose  to  180.  On  the  next  day  it  again  sank  without  the  use  of  coronilin,  to 
84,  and  did  not  rise  again.  The  patient,  however,  became  worse,  and  died 
after  eighteen  days. 

At  the  autopsy  there  were  found  fatty  degeneration  of  the  heart,  general 
arterio-sclerosis,  and  some  hemorrhagic  pachymeningitis,  with  considerable 
clear  fluid  in  the  ventricles.  Dehio  considers  that  the  ansemia  of  the  medulla 
following  the  operation,  was  undoubtedly  the  cause  of  the  rapid  pulse.  This 
either  stimulated  the  accelerator  or  paralyzed  the  inhibitory  centre.  Extreme 
frequency  of  the  heart-beat,  with  weak  cardiac  impulse,  and  no  arhythmia, 
indicates,  according  to  Nothnagel,  paralysis  of  the  inhibitory  apparatus;  and 
Traube  has  reported  a  case  which  he  explains  in  a  similar  manner.  The 
author  believes  that  this  is  also  the  correct  explanation  in  his  case.  It  is 
scarcely  possible,  moreover,  that  stimulation  of  the  accelerator  apparatus 
should  have  continued  so  many  days  without  any  sign  of  fatigue  of  the  centre. 
As  the  abdomen  began  to  fill  with  fluid  again,  the  medulla  became  engorged 
with  blood,  and  the  vagus  resumed  its  normal  functions. 

The  Etiology  of  Endocarditis. 

Frankel  and  Sanger  (Virchow's  Archiv,  B.  cviii.  H.  2,  286-397),  while 
admitting  that  bacteriological  studies  of  later  years  have  shown  that  the  most 
different  forms  of  disease  may  depend  on  the  same  germ — tuberculosis  being, 
perhaps,  the  best  example  of  this  fact — say  that  the  same  studies  teach  that 
sometimes  different  microorganisms  may  produce  similar  clinical  symptoms. 
Endocarditis  is  a  case  in  point,  and  the  authors  have  endeavored  to  determine 
what  forms  of  it  were  caused  by  microorganisms,  and  which  of  these  bodies 
were  the  factors  in  each  case.  They  report  thirteen  cases  examined  bacterio- 
logically  during  the  last  year ;  detailing  in  full  their  methods  of  procedure, 
both  as  regards  the  culture  of  the  microbes  and  the  inoculation  of  the  same 
in  animals,  and  giving  the  conclusions  derived  from  their  experiments.  They 
found  eight  species  of  microbes  in  all,  six  of  which  were  pathogenic.  In 
studying  the  cases  with  reference  to  these  organisms,  the  authors  show  that 
there  is  no  one  variety  which  is  the  specific  cause  of  endocarditis.  Sometimes 
one  species,  was  found  in  the  deposit  on  the  endocardium,  sometimes  another; 
and  in  one  instance  three  different  kinds  were  detected.  The  staphylococcus 
pyogenes  flavus  was  the  one  by  far  most  frequently  present.  It  has  been 
proved  that  many  species  of  microorganisms  may  be  made  to  produce  artificial 
endocarditis.  Netter  even  found  the  pneumococcus  of  A.  Frankel  in  the 
vegetations  of  eight  cases  of  endocarditis  complicating  pneumonia,  and  suc- 
ceeded in  producing  endocarditis  in  rabbits  with  it. 

It  is  worthy  of  note  that  the  microbes  showed  such  continued  vitality  in 
some  of  the  authors'  cases,  where  the  affection  of  the  endocardium  was  cer- 
tainly very  old.  This  may  explain  the  tendency  so  often  observed  toward  a 
recurrence  of  endocarditis.  Yet  their  vitality  is  not  unlimited,  and  the  nega- 
tive bacteriological  results  of  some  of  the  cases  may  have  been  due  to  the 
death  and  disappearance  of  the  bacteria  formerly  present.  They  believe  with 
Weichselbaum,  Klebs,  and  Koster,  that  verrucose  as  well  as  ulcerative  endo- 
carditis is  a  disease  of  purely  mycotic  origin,  and  think  that  the  two  forms 


540 


PROGRESS  OF   MEDICAL  SCIENCE. 


should  not  be  separated  etiologically.  But  as  they  have  noticed  repeatedly 
that  the  microbes  are  far  less  abundant  in  the  verrucose  forms,  they  believe 
that  the  number  present  may  have  some  influence  in  determining  the  type  of 
the  disease. 

Atheromatous  endocarditis  is  the  only  kind  which  is  certainly  non-mycotic. 
The  true  nature  of  the  so-called  fibrous,  sclerotic,  chronic  variety  is  doubtful. 
It  seems  not  improbable  that  it  is  frequently  only  the  terminal  stage  of  a  ver- 
rucose endocarditis,  and  hence  is  of  mycotic  origin. 

It  is  a  remarkable  fact  that  coagulation-necrosis  is  the  lesion  usually 
observed  on  the  valves,  and  that  true  suppuration  so  rarely  occurs,  although 
the  pyogenic  staphylococci  are  the  ones  usually  present.  This  may  be  due  to 
some  peculiarity  of  the  bloodvessel  supply,  for  it  has  been  noticed  in  some 
cases  that  while  the  valves  have  become  coagulation -necrotic,  abscesses  have 
developed  in  the  heart  muscle.  On  the  other  hand,  the  presence  of  some 
other  microbe  with  the  staphylococci  may  in  some  way  modify  the  action  of 
the  latter.  The  authors  agree  with  Orth  that  the  bacteria  are  usually  deposited 
directly  on  the  valves  from  the  blood  current;  but  believe,  too,  that  in  some 
cases  they  may  reach  their  destination  through  the  coronary  arteries.  Regard- 
ing the  question,  whence  and  how  the  microbes  gain  access  to  the  valves,  it  is 
interesting  to  note  that  in  seven  of  the  cases  reported  suppuration  was  going 
on  somewhere  in  the  body. 

That  the  left  side  of  the  heart  is  the  one  usually  attacked,  may  be  due,  as 
Virchow  supposes,  to  the  greater  blood-pressure  forcing  the  bacteria  between 
the  endothelial  cells.  The  authors  are,  however,  inclined  to  the  view  that  it 
is  because  the  microbes  develop  better  in  the  oxygenated  blood  of  the  left 
heart,  since,  as  Liborious  has  shown,  oxygen  is  necessary  for  their  vital 
activity. 

contribution  to  the  determination  of  the  percussion  llmits  of 

the  Stomach. 

Pacanowski  {Deutsche  Arch./,  hlln  Med.,  B.xl.  H.  3  and  4,  342),  in  speak- 
ing of  the  limitations  to  the  physical  examination  of  the  stomach,  says  that 
Penzoldt's  method  for  determining  its  boundaries  by  pouring  in  water  through 
the  sound,  and  then  outlining  the  position  of  the  dulness,  is  accurate  but 
unpleasant,  and  dangerous  if  ulcer  be  present.  The  same  is  true  of  Leube's 
process  of  feeling  for  the  end  of  the  sound  through  the  abdominal  and  gastric 
walls.  Bosenbach's  and  Schreiber's  methods  are  too  complicated  for  ordinary 
use.  Frerichs's  device  of  dilating  the  stomach  with  carbonic  dioxide,  and 
then  percussing,  is  not  accurate,  and  may  be  attended  by  danger. 

The  author  has  examined  eighty-one  cases  (fifty-five  men  and  twenty-six 
women)  by  simple  percussion  ;  sometimes  two  to  three  hours  after  the  chief 
meal,  sometimes  when  no  food  had  been  taken,  and  has  corroborated  his 
results  in  many  cases  by  employing  Penzoldt's  method.  Of  the  four  bounda- 
ries to  be  determined,  the  lower  is  the  most  important  for  practical  purposes. 
The  others  vary  but  little,  except  when  artificially  distended  with  carbonic 
dioxide ;  and  to  determine  them  the  patient  was  always  examined  while  upon 
his  back.  The  lower  part  of  ths  right  border  can  scarcely  be  determined  by 
simple  percussion,  since  it  lies  below  the  edge  of  the  liver,  and  to  the  right 
of  the  middle  line.   When,  however,  the  viscus  is  artificially  dilated  with  gas, 


MEDICINE. 


541 


the  difference  between  the  sound  of  this  part  of  the  stomach  and  that  of  the 
adjacent  colon  can  be  often  distinguished.  The  upper  part  of  the  right  border 
is  very  easily  determined  by  ordinary  percussion.  The  left  boundary  cannot 
be  located  with  certainty.  The  upper  border  is  partially  covered  by  the  lung, 
hence  deep  percussion  shows  us  the  actual  upper  limit  of  the  stomach,  while 
light  percussion  reveals  the  portion  not  at  all  covered  by  pulmonary  tissue. 
The  first  of  these  reached,  as  a  rule,  the  lower  edge  of  the  fifth  rib,  or  the  fifth 
interspace  in  the  left  parasternal  line ;  the  fifth  interspace  or  the  lower  edge 
of  the  sixth  rib  in  the  left  mamillary  line,  and  the  lower  margin  of  the  seventh 
rib,  or  upon  the  eighth  rib  in  the  left  anterior  axillary  line.  To  determine 
the  lower  border  of  the  stomach,  the  author  first  examined  the  patient  while 
recumbent,  in  order  to  discover  whether  the  organ  could  be  distinguished 
from  the  colon.  Its  percussion  tone  is  more  tympanitic  and  duller  than  that 
of  the  large  intestine,  and  frequently  varies  slightly  with  respiration.  He 
now  let  the  patient  stand,  administered  a  half  litre  of  water,  and  sought  for 
a  line  of  percussion  dulness,  which  would  disappear  when  the  patient  again 
assumed  the  recumbent  position.  This  line  marked  the  lower  border.  There 
are  some  difficulties  with  this  plan,  viz.,  that  on  standing,  the  whole  gastric 
region  often  becomes  dull,  owing  to  the  unavoidable  tension  of  the  abdominal 
walls.  Yet  the  dulness  of  the  water  in  the  viscus  can,  as  a  rule,  be  detected 
if  care  be  used.  The  author  further  employed  Frerichs's  method  in  all  cases, 
excepting  those  in  which  there  was  heart  disease,  or  a  gastric  ulcer  was  sus- 
pected. Too  great  distention  must  not  be  allowed,  or  the  true  boundaries 
become  displaced,  and  false  results  are  obtained.  He  locates  the  lower  border 
of  the  stomach  at  a  distance  above  the  navel  in  the  parasternal  line  of  3-5 
centimetres  in  men,  4-7  centimetres  in  women.  He  has  never  seen  it  extend 
below  the  navel.  In  his  own  cases  he  found  the  stomach  to  be  7  to  20  centi- 
metres in  height  in  men,  the  average  being  11-14  centimetres.  In  women,  it 
varied  from  7  to  13,  with  an  average  of  10  centimetres.  The  breadth  in  men 
was  usually  21  centimetres,  the  maximum  being  25,  the  minimum  16.  In 
women  it  varies  from  15  to  22,  the  average  being  18  centimetres.  Thus  the 
relation  of  the  height  to  the  breadth  in  men  is  1 : 1.5  or  2,  and  in  women 
about  1 : 2. 

Dysentery,  and  the  Meteorological  Conditions  Influencing  It. 

Hippius  {Deutsches  Archiv  f.  klin.  3fed.,  Bd.  xl.,  H.  3  und  4,  284)  publishes 
an  elaborate  article  on  this  subject  with  six  tables,  five  of  which  contain 
graphic  curves  showing  the  relation  of  the  daily  number  of  cases  of  dysentery 
-during  five  years  to  various  meteorological  conditions.  His  observations  are 
founded  on  2507  cases  treated  at  the  St.  "Wladimir  Children's  Hospital  in 
Moscow.  The  sixth  table  gives  two  curves  comparing  the  number  of  cases 
of  dysentery  with  that  of  catarrh  of  the  stomach  and  small  intestine  taken 
together,  and  showing  that  they  are  almost  parallel. 

The  conclusions  drawn  from  his  tables  are: 

1.  Either  continued  elevation  of  the  temperature  of  the  air,  or  a  sudden 
■cooling  of  the  same,  increases  the  number  of  cases  of  dysentery. 

2.  Dysentery  begins  in  spring  when  the  temperature  exceeds  50°  F.,  but 
may  continue  into  autumn  even  when  the  meteorological  conditions  are  not 
favorable  to  its  existence. 


542 


PKOGRESS  OF  MEDICAL  SCIENCE. 


3.  Dampness  of  the  air  is  favorable  to  the  development  of  the  disease.  The 
number  of  cases  in  hot  weather  increases  if  there  is  a  sudden  increase  of 
humidity,  and  especially  if  there  is  a  simultaneous  diminution  in  the  tem- 
perature of  the  air. 

4.  The  injurious  influence  of  these  sudden  variations  in  temperature  and 
humidity  is  more  noticeable  in  the  first  half  of  the  summer  than  in  the 
second. 

5.  Very  cloudy  weather,  high  winds,  and  a  large  amount  of  ozone  in  the 
atmosphere  are  rather  unfavorable  to  the  development  of  dysentery,  but  their 
influence  is  only  secondary. 

6.  Barometrical  pressure,  the  amount  of  rain-fall,  the  number  of  rainy 
days,  and  the  number  of  thunder  storms  have  no  influence  on  the  disease. 

The  maximum  age  of  the  patients  whom  he  examined  was  about  twelve 
years.  In  the  beginning  of  summer  two-thirds  of  the  cases  were  under  two 
years  of  age,  but  in  August  and  September  the  greater  number  were  older 
than  this.  He  is  of  the  opinion  that  epidemic  and  sporadic  dysentery  are 
identical,  and  that  every  case  must  be  considered  of  a  contagious  nature; 
though  in  just  what  way  sporadic  cases  become  thus  infectious  cannot  as  yet 
be  explained. 

Functional  Diseases  of  the  Liver. 

Fenwick  {Lancet,  1887,  i.  1171,  1217,  1271)  has  for  years  been  endeavor- 
ing to  determine  whether  any  of  the  secretions  would  show  how  completely 
the  hepatic  functions  were  being  performed  ;  and  has  discovered,  he  believes, 
that  the  amount  of  the  sulphocyanide  in  the  saliva  might  be  taken  as  the 
index  of  the  activity  of  the  liver. 

Specimens  of  the  saliva  mixed  with  a  solution  of  the  perchloride  of  iron 
produced  blood-red  tints  of  varying  intensity,  depending  on  the  amount  of 
sulphocyanide  present. 

These  tints  were  compared  with  a  scale  of  colors  which  the  author  had  had 
prepared,  or  with  a  series  of  solutions  of  the  sulphocyanide  of  iron  of  known 
strengths,  varying  in  both  directions  from  a  shade  called  "  normal " — this 
shade  being  obtained  by  the  examination  of  the  saliva  of  a  large  number  of 
healthy  persons.  In  this  way  he  made  thousands  of  examinations,  and  com- 
pared the  amount  of  sulphocyanide  with  the  symptoms  of  each  case. 

In  health  there  was  comparatively  little  variation,  the  saliva  of  females 
giving  a  shade  oftener  slightly  below  than  above  the  normal  color.  In 
typhoid  fever  the  amount  of  sulphocyanide  was  greatly  diminished;  increas- 
ing suddenly  when  the  temperature  fell  and  convalescence  began.  Some- 
times the  increase  became  evident  a  week  before  the  fever  disappeared,  and 
constituted  a  valuable  prognostic  sign.  Instances  of  other  diseases  are  also 
quoted  to  show  that  when  there  was  a  gain  in  weight  and  strength,  with 
greater  activity  of  the  digestive  organs,  the  amount  of  the  salt  was  increased  ; 
but  that  it  was  diminished  if  emaciation  was  progressing.  The  sudden  change 
from  an  abundant  to  a  scanty  secretion  in  any  disease  where  a  drain  was 
made  upon  the  organism — as  in  chronic  nephritis — indicated  the  commence- 
ment of  failing  strength  and  health — i.  e.,  the  expenditure  was  exceeding  the 
income  of  the  system. 


MEDICINE. 


54a 


This  change  is  best  explained  by  supposing  an  alteration  from  a  condition 
of  overstimulation  to  one  of  depression  of  the  digestive  organs. 

Inquiry  into  the  state  of  the  salivary  salt  in  diseases  of  these  organs  where 
no  demand  was  made  on  them  for  special  exertion  (as  is  the  case  in  wasting 
diseases)  showed  a  positive  relation  of  the  quantity  of  the  salt  to  the  condi- 
tion of  the  digestive  tract.  In  atonic  dyspepsia,  and  in  chronic  diarrhoea  and 
dysentery  the  sulphocyanide  was  decidedly  diminished;  and  in  cancer  of  the 
stomach  this  was  very  early  the  case,  before  cachexia  and  emaciation  had 
begun.  In  some  cases  of  ascites  from  cirrhosis  of  the  liver  it  was  much 
below  normal;  rising  at  once  and  very  greatly  after  tapping.  This  rise  was- 
probably  due  to  the  relief  of  the  pressure  on  the  portal  vessels  and  of  the  pas- 
sive congestion  of  the  digestive  organs.  It  was  not  due  to  impaired  digestion 
itself:  for  in  cases  of  ascites  where  the  stomach  also  was  disordered,  tapping 
produced  no  improvement  in  the  amount  of  sulphocyanide.  In  jaundice  the 
salt  was  very  deficient,  and  Fenwick  thinks  it  probable  that  bile  must  enter 
the  intestine  in  order  that  sulphocyanide  be  secreted.  Acute  congestion  of 
the  liver  exhibited  augmented  secretion.  In  chronic  congestion  following  car- 
diac dilatation  or  mitral  disease  the  amount  was  diminished,  but  when  steady 
improvement  in  the  symptoms  took  place  a  weekly  increase  in  the  quantity 
of  the  salt  was  observed.  As  regards  other  diseases,  there  was  a  striking  aug- 
mentation of  the  sulphocyanide  in  acute  rheumatism,  but  none  in  chorea. 
In  gout  and  urticaria  the  secretion  was  above  normal.  Headache,  especially 
of  the  bilious  variety,  was  very  common  in  persons  exhibiting  an  increase  of 
the  salt;  while  in  headache  of  a  purely  neuralgic  nature  the  quantity  was 
usually  diminished.  A  great  excess  of  it  in  old  people  was  sometimes  the 
precursor  of  grave  changes  in  the  vascular  system. 

Fenwick  claims  that  the  origin  of  the  sulphocyanide  is  plainly  connected 
with  the  exercise  of  the  nutritive  functions.  Its  relations  to  ascites,  and  its 
diminution  in  jaundice  show  that  it  is  not  due  simply  to  chemical  changes 
the  result  of  gastric  digestion.  Lead  is  said  to  be  directly  depressant  to  the 
action  of  the  liver ;  and  it  is  a  remarkable  fact  that  in  every  case  of  lead  colic 
which  the  author  examined  the  sulphocyanide  was  absent  from  the  saliva. 
The  same  circumstances  tending  to  promote  a  free  secretion  of  bile  are  accom- 
panied by  a  free  secretion  of  the  salivary  salt;  and  the  author  concludes  that 
its  presence  in  the  saliva  is  connected  with  the  action  of  the  hepatic  cell.  He 
believes  that  it  is  formed  from  one  of  the  constituents  of  the  bile — the  tauro- 
cholate  of  soda — after  it  has  reached  the  duodenum.  But  the  formation  of 
the  taurocholate  of  soda  depends  on  a  full  supply  and  digestion  of  albuminous 
food ;  for  it  is  probably  developed  from  peptones  after  they  have  been  absorbed 
from  the  intestines.  Hence  the  sulphocyanide  is  dependent  primarily  on  the 
action  of  the  other  organs  of  digestion  as  well  as  on  the  hepatic  cell,  though 
we  are  justified  in  taking  its  amount  as  the  index  of  the  action  of  the  liver 
especially. 

So  far  as  therapeutic  indications  are  concerned,  Fenwick  advises  that  the 
use  of  alcohol  be  stopped,  and  the  amount  of  albuminous  and  fatty  food 
diminished  when  the  salivary  salt  is  abnormally  abundant.  In  the  reverse 
condition  tonics  and  a  liberal  diet  are  to  be  employed.  Lead  is  the  only  drug 
capable  of  directly  diminishing  the  amount  of  sulphocyanide,  though  other 


544 


PROGRESS  OF   MEDICAL  SCIENCE. 


substances  affect  indirectly.  Cod  liver  oil  seems  especially  efficacious  in  in- 
creasing the  quantity. 

On  a  Peculiar  Occurrence  of  White,  Clay-colored  Stools. 

Under  this  title  Pel  (Centralb.  f.  klin.  Med.,  1887,  No.  17,  297)  writes  that 
the  brown  color  of  the  normal  feces  is  due  to  two  factors;  1st.  Decomposed 
biliary  matters,  and  2d.  The  nature  of  the  food  taken.  Under  pathological  con- 
ditions or  after  certain  medicines  the  natural  color  may  be  altered.  White, 
clay-colored  stools  have  always  been  considered  absolutely  characteristic  of 
complete  obstruction  of  the  ductus  choledochus,  with  the  consequent  total 
.absence  of  bile  from  the  intestines;  the  feces  containing  undigested  fat.  The 
.author  reports  a  case  in  which  typical  clay-colored  passages  occurred  without 
any  such  obstruction.  The  patient  had  a  history  of  attacks  of  biliary  colic, 
and  at  the  time  of  examination  there  were  icterus,  enlargement  of  the  liver, 
urine  containing  bile,  and  the  typical  stools  referred  to.  In  a  few  days  the 
icterus  and  biliary  urine  had  disappeared ;  some  enlargement  of  the  liver  re- 
maining. During  four  months  the  patient  had  several  light  attacks  of  colic 
from  gall-stone;  and  three  times  exhibited  slight  icterus  for  a  few  days. 
During  the  whole  time  there  was  not  the  slightest  change  in  the  character  of 
the  stools,  which  were  always  white  and  clay-colored  in  spite  of  a  mixed  diet 
containing  comparatively  little  fat.  The  cause  of  this  peculiar  condition  was 
a  question  of  great  interest.  There  was  certainly  no  degeneration  of  the  liver 
cells,  for  the  patient  was  in  excellent  general  health.  That  icterus  and  biliary 
urine  had  existed,  and  that  the  passages  had  no  unusually  unpleasant  odor 
proved  that  the  bile  was  not  lacking  in  some  important  constituents  (as  in 
the  bile  incolore  of  Eitter  and  Charcot).  Careful  chemical  and  spectroscopic 
examination  showed  that  the  bile  in  toto  and  in  sufficient  quantity  had  entered 
the  intestine.  Perhaps  in  this  case  it  was  transformed  chiefly  into  chromogen 
instead  of  into  urobilin  as  under  normal  conditions. 

Cause  of  the  Red  Color  of  Non-saccharine  Urine  on  adding 
Picric  Acid  and  Potash. 

In  view  of  the  extended  use  of  picric  acid  as  a  test  both  for  albumin  and 
glucose,  it  is  well  to  be  aware  of  the  fact  that  a  saturated  watery  solution  of 
this  reagent  produces  in  normal  human  urine  a  precipitate,  which,  according 
to  Jaffe  (Zeilschr.  f.  physioL  Chemie,  vol.  x.  p.  891)  consists  of  uric  acid 
crystals,  and  of  fine  needles  of  creatinine-potassium  picrate.  The  picric 
acid,  it  is  said,  precipitates  uric  acid  even  more  completely  than  hydro- 
chloric acid.  Furthermore,  if  to  a  solution  of  creatinine  a  little  picric  acid 
solution  and  then  a  few  drops  of  a  solution  of  caustic  soda  or  potash  be 
added,  the  mixture  will  assume  at  once,  and  in  the  cold,  a  beautiful  red  color, 
which  is  turned  yellow  by  acetic  or  nitric  acids.  This  reaction  (which  all 
who  have  employed  the  picric  acid  test  for  glucose  must  have  noticed)  can  be 
obtained  in  a  solution  of  1 :  5000,  and  is,  therefore,  directly  applicable  to  the 
urine.  Acetone  gives  a  similar  reaction,  but  the  red  color  has  a  yellow  shade. 
Creatine  gives  a  yellow  color  at  once,  which  only  gradually  changes  to  red. 
Other  bodies — such  as  glucose  and  uric  acid — give  the  red,  but  only  on  heating. 


SURGEKY. 


545 


Two  New  Pathological  Coloring  Matters  in  Urine. 

In  a  patient  suffering  from  osteomalacia,  cystitis,  and  nephritis,  Leube 
(Archiv  f.  path.  Anat.)  observed  that  the  urine  became  of  a  dark  violet  or 
almost  black  color  on  being  exposed  to  the  air.  The  (amorphous)  coloring 
matter  is  soluble  in  ether,  from  which  it  can  be  extracted  by  dilute  alkalies, 
but  not  by  acids.  The  alkaline  solution  is  at  first  brownish-red,  and,  later, 
yellow.    It  is  soluble  in  hot  water,  chloroform,  benzol,  etc. 

In  the  urine  of  a  woman  afflicted  with  malignant  hepatic  disease,  Thor- 
malen  ( Virchow's  Archiv,  vol.  cviii.  p.  317)  observed  in  using  the  sodium 
nitroprusside  and  caustic  soda  test  an  unusual  reaction.  The  primary  red 
color,  namely,  on  the  addition  of  acetic  acid  neither  became  lighter,  nor 
changed  to  crimson  (acetone),  but  turned  a  beautiful  blue,  which  became 
red  and  blue  again  alternately  on  adding  an  alkali  or  acid.  He  found  the 
coloring  matter  causing  this  reaction  to  occur  normally  in  the  urine  of  horses 
and  cats,  from  which  it  can  be  separated  by  the  action  of  plumbic  acetate. 

Cause  of  the  Development  of  Sulphuretted  Hydrogen  in  Urine. 

Under  pathological  conditions  it  sometimes  occurs  that  the  urine  while  still 
in  the  bladder  contains  H2S.  Many  hypotheses  have  been  advanced,  with 
more  or  less  success,  to  account  for  this  condition,  such  as  absorption  from 
the  neighboring  intestine,  etc. 

In  a  case  of  cystitis,  characterized  by  the  freshly  voided  urine  containing 
great  quantities  of  H2S,  Rosenheim  [Fortschritte  d.  Med.,  vol.  v.  p.  345)  was 
able  to  isolate  from  the  urine  a  bacillus  which  appears  to  have  the  property 
of  causing  the  evolution  of  this  gas.  It  also  has  feeble  powers  of  decompos- 
ing urea  into  ammonium  carbonate.  The  author  omits  to  state  whether 
catheters  had  been  used  in  the  case,  but  it  is  to  be  presumed  that  they  had 
been  and  that  they  were  the  means  of  introducing  the  bacillus. 

In  this  connection  it  may  be  of  interest  to  note  that  Rattone  and  Valenta 
(Archivio  per  le  scienze  mediche,  vol.  x.,  p.  311)  have  discovered  a  micrococcus 
which  causes  hippuric  acid  to  be  changed  into  benzoic  acid  and  glycocoll. 
This  accounts  for  the  spontaneous  disappearance  of  the  hippuric  acid  from 
urine  exposed  to  the  air. 


SURGERY. 

In  Europe, 
under  the  charge  of 
FREDERICK  TREVES,  F.R.C.S., 

SURGEON  TO,  AND  LECTURER  ON  ANATOMY  AT,  THE  LONDON  HOSPITAL. 


Recent  Surgical  Literature. 

The  following  volumes  of  the  Dictionnaire  Encyclopedique  des  Sciences  Medi- 
cates have  appeared  since  the  last  issue  of  this  journal.  The  volume  "Phan  " 
to  "Phos"  contains  a  very  useful  and  careful  article  on  the  "  Pharynx,"  by 

NO.  CLXXXVIII.— OCTOBER,  1887.  35 


546 


PROGKESS  OF  MEDICAL  SCIENCE. 


MM.  Arxogax  and  Moure.  The  pathology  of  the  pharynx  is  very  fully 
dealt  with.  M.  Mathieu  contributes  the  monograph  on  "Phyinosis"  and 
"Paraphymosis."  The  work  is  exceptionally  verbose,  and  occupies  no  less 
than  seventy-two  closely  printed  pages.  The  value  of  the  article  is  seriously 
damaged  by  its  diffuseness. 

The  article  on  "  Phlebitis  "  is  disappointing  and  not  up  to  date.  It  ignores 
the  important  contributions  of  recent  German  writers  to  our  knowledge  of  this 
affection. 

In  the  volume-  "  Thro  "  to  "Traf"  the  principal  surgical  papers  are  the 
following:  "Thymus,"  a  very  valuable  paper.  "Thyroid:"  The  Anatomy 
and  Physiology  of  the  Gland,  by  Drs.  Herrmann  and  Tourxeattx;  and 
the  diseases  of  the  same,  by  Broca.  The  latter  monograph  is  singularly 
complete  and  well  up  to  date.  "Tibia:"  An  account  of  the  anatomy  of  the 
bone,  and  of  the  fractures  incident  to  it,  by  M.  Heydexreich.  "  Torticollis," 
by  M.  Guyox.    "Trachea  and  Tracheitis,"  by  M.  Chermoxt. 

The  volume  "Epid"  to  "Erec"  contains  a  very  excellent  monograph  on 
"  Epistaxis,"  by  MM.  Torgue  and  Boixet. 

In  the  volume  "Ute"  to  "Val"  the  papers  on  the  "Uterus"  are  completed, 
and  an  excellent  account  of  the  "Anatomy,  Physiology,  and  Pathology  of 
the  Vagina"  is  furnished  by  M.  Petit. 

The  volume  "Hsema  to  Hemor"  contains  a  very  useful  treatise  on  "Hsema- 
tocele,"  by  M.  Paul  Recltjs;  a  feeble  monograph  on  "  Hsematuria,"  by 
Dr.  Bourel-Roxciere  ;  and  the  commencement  of  an  elaborate  paper  on 
"Hemorrhage." 

Internal  Derangements  of  the  Knee-joint.  By  Dr.  Scott  Laxg  (Edinburgh, 
1887).  This  little  monograph  represents  the  author's  graduation  thesis.  It 
deals  solely  with  luxations  and  subluxations  of  the  semilunar  cartilages  of  the 
knee-joint.  The  luxation  of  either  cartilage  may  be  complete  or  incomplete. 
In  no  case  would  it  appear  that  both  cartilages  may  be  displaced  at  one  time. 
The  incomplete  displacements  are  the  more  usual,  the  complete  being  rare. 
The  internal  cartilage  is  much  more  frequently  displaced  than  the  external. 
The  author  enters  at  length  into  the  anatomy  and  causation  of  the  lesion,  and 
this  portion  of  the  monograph  is  very  valuable.  He  shows  that  luxation  of 
the  internal  cartilage  occurs  when  the  leg  is  rotated  outward,  while  luxation 
of  the  outer  cartilage  follows  an  inward  rotation  of  the  limb.  In  the  matter 
of  treatment  the  author  has  nothing  new  to  propose. 

Leitfaden  zur  antiseptischen  Wundbehandlung ,  by  Prof.  Nussbatjm  (Stutt- 
gart, 1887).  This  guide  to  the  antiseptic  treatment  of  wounds  has  now 
reached  the  fifth  edition,  and  when  compared  with  the  first  issue  it  is  practi- 
cally a  new  work.  It  forms  a  treatise  upon  the  circumstances  of  wound  heal- 
ing that  has  no  rival.  It  is  singularly  complete.  The  subjects  of  infection  of 
wounds,  of  fat  embolism,  of  the  accidents  and  morbid  states  of  wounds,  are 
all  dealt  with  at  considerable  length,  and  in  an  admirable  manner.  Under 
the  heading  of  antiseptic  materials  used  in  the  treatment  of  wounds  no  less 
than  eighty  different  substances  are  described.  Not  only  is  every  possible 
form  of  dressing  described,  but  in  special  sections  the  best  mode  of  treating 
wounds  of  individual  parts  is  fully  discussed.  The  author  accepts  the  ex- 
pression antiseptic  treatment  in  its  very  widest  sense. 


SURGERY. 


547 


Die  Verwerthung  der  Bacteriologie  in  der  klinischen  Diagnostic,  by  Dr.  Gott- 
stein  (Berlin,  1887).  This  work  considers,  as  the  title  explains,  the  part 
played  by  bacteriology  in  clinical  diagnosis.  It  does  not  profess  to  be  an 
original  work,  but  rather  a  summary  and  review  of  our  present  knowledge  of 
this  subject.  Such  a  manual  is  of  great  value  to  the  busy  physician  or  sur- 
geon, as  it  presents  a  crude  and  unwieldy  mass  of  material  in  an  assimilable 
form.  The  following  are  the  main  affections  dealt  with :  typhus,  cholera, 
erysipelas,  tuberculosis,  leprosy,  pneumonia,  rhinoscleroma,  syphilis,  gonor- 
rhoea, suppuration,  anthrax,  malignant  oedema,  actinomycosis. 

Diagnostik  der  chirurgischen  Krankheiten,  by  Prof.  Albert  (Vienna,  1887). 
This  is  the  fourth  edition  of  a  well-known  work  on  surgical  diagnosis.  It 
has  been  added  to,  and  brought  well  up  to  date.  The  book  forms  a  most 
admirable  elementary  text-book.  It  is  short  and  concise.  It  does  not  cover 
the  whole  field  of  surgical  diagnosis,  but  deals  with  the  most  conspicuous 
difficulties  that  come  in  the  way  of  the  learner.  The  manual  would  be  of 
greater  value  if  it  were  better  illustrated. 

Herniologische  Streitfragen,  by  Prof.  W.  Roser  (Marburg,  1887).  This 
little  work  on  "Disputed  points  connected  with  Hernia,"  will  be  read  with 
great  interest  by  surgeons,  especially  by  those  who  are  acquainted  with  Prof. 
Roser's  masterly  contribution  to  surgery.  The  points  discussed,  and  the 
general  character  of  the  work,  may  be  illustrated  by  the  following  headings : 
A  hernia  does  not  form  suddenly.  Corpulence  as  a  cause  of  hernia.  Forma- 
tion of  a  hernial  sac  by  local  stretching  of  the  peritoneum.  The  constricting 
cause  in  strangulation.  Venous  engorgement  and  arterial  arrest  in  the 
strangulated  loop.  Partial  hernia.  Pseudo-strangulation.  Whence  comes 
the  fluid  in  the  hernial  sac  ?  Radical  operation. 

Handbuch  der  Massage,  by  Dr.  Hu^erfauth  (Leipzig,  1887).  This  very 
complete  and  exhaustive  treatise  upon  massage  forms  an  important  addition 
to  modern  medical  literature.  The  author  enters  fully  into  the  physiology  of 
the  measure,  and  into  the  precise  details  attending  its  employment.  So  far 
as  surgery  is  concerned  massage  is  dealt  with  in  connection  with  the  following 
affections :  Joint  affections  of  all  kinds.  Fractures,  lumbago,  muscular 
rheumatism,  hernia,  scrofulous  gland  diseases,  varices,  flatfoot,  hypertrophy 
of  the  prostate,  and  some  other  diseases.  It  is  to  be  hoped  that  an  edition  of 
the  book  will  appear  in  English. 

Pratique  de  la  Chirurgie  des  voies  urinaires,  by  Dr.  Delefosse  (Paris,  1887) 
This  is  the  second  edition  of  a  fairly  well-known  work  upon  genito-urinary 
surgery.  The  section  on  the  anatomy  of  the  parts  is  good,  although  the 
author,  like  most  French  surgeons,  ascribes  wonderful  properties  to  "  Wilson's 
muscle."  The  chapter  on  catheterism  is  verbose.  The  section  on  the  treat- 
ment of  stricture  deals  largely  with  instruments,  and  gives  especial  promi- 
nence to  internal  urethrotomy.  Little  or  no  mention  is  made  of  the  work  of 
English  surgeons.  The  work  would  be  quite  out  of  date  but  for  that  in  an 
appendix  some  account  is  given  of  litholapaxy,  suprapubic  lithotomy,  and  the 
treatment  of  vesical  tumors. 


548 


PEOG-RESS  OF   MEDICAL  SCIENCE. 


Ueber  maligne  Neurome,  by  Dr.  Krattse,  is  the  last  surgical  contribution  to 
Volkmann's  Sammlung.  It  forms  a  very  complete  monograph  upon  malignant 
or  rapidly  growing  tumors  of  nerves,  dealing  with  sarcomatous  and  myxo- 
matous neuromata.  The  author  gives  some  illustrative  cases  and  abstracts 
of  a  number  of  recorded  examples.  He  makes  a  special  point  of  the  new 
formations  of  nerve  fibres  that  are  occasionally  found  in  these  growths. 

Fragments  de  chirurgie  contemporaines,  by  Dr.  Brisay  (Paris,  1887).  This 
book  consists  of  a  sketch  of  what  the  author  saw  in  the  department  of  surgery 
during  a  scientific  tour.  It  concerns  itself  mainly  with  operative  gynecology. 
The  book  is  well  illustrated,  but  it  is  fragmentary,  purposeless,  and  unreliable, 
and  admirably  adapted  for  "private  circulation  only." 

Etude  sur  les  Kystes  Hydatiques  du  Rein,  by  Jules  Bceckel  (Paris,  1887). 
This  forms  a  very  valuable  monograph  upon  hydatid  cysts  of  the  kidney. 
The  author  deals  with  the  subject  in  a  very  complete  manner,  discussing  the 
etiology,  the  clinical  aspect,  and  the  surgical  treatment  of  the  disease.  The 
work  is  illustrated  by  a  number  of  instructive  and  well-recorded  cases.  It 
forms  an  important  addition  to  the  literature  of  renal  surgery. 

Abdominal  Section. 

Sir  William  MacCormac  {Lancet,  May  7,  1887)  in  an  eminently  prac- 
tical lecture  reviews  the  subject  of  laparotomy  for  wound  or  rupture  of  the 
intestines.  Only  two  new  cases  are  recorded,  one,  a  patient  under  the  care  of 
Mr.  Croft,  in  whom  laparotomy  was  performed  eighteen  hours  after  a  severe 
crush  of  the  abdomen.  A  large  wound  was  found  in  the  ileum  with  a  rupture 
of  the  mesentery  and  omentum,  septic  peritonitis  being  already  present.  An 
artificial  anus  was  made,  the  peritoneal  cavity  being  thoroughly  cleansed. 
Four  weeks  later  an  attempt  was  made  to  close  the  artificial  anus,  the  ends 
being  resected  and  Lembert's  sutures  being  employed.  The  patient,  who  was 
already  much  enfeebled,  survived  the  protracted  operation  only  a  few  hours. 

In  the  second  case,  one  of  bullet  wound,  the  abdomen  was  opened  and  the 
intestine  found  to  be  perforated,  but  the  wound  could  not  be  closed. 

M.  Fenillon  {Gazette  des  Hopitaux,  June,  1887)  performed  abdominal 
section  in  three  cases  of  pelvic  abscess  in  women,  "  suturing  the  abscess  wall 
to  the  edges  of  the  wound,"  in  two  with  a  very  good  result.  In  the  third 
case  the  abscess  had  already  burst,  producing  acute  general  peritonitis,  to 
which  the  patient  succumbed. 

The  subject  and  statistics  of  gastroenterostomy  are  treated  with  characteristic 
German  verboseness  in  a  long  article  by  Dr.  Rockwitz  in  the  Deutscher  Zeit- 
schrift  fur  Chirurgie  for  June  22,  1887,  who  has  collected  details  of  22  cases, 
performed  either  for  carcinoma  or  stricture  about  the  pylorus,  and  the  fol- 
lowing is  an  analysis  of  the  final  results.  2  cases  appear  to  have  been 
completely  cured  (both  were  performed  for  simple  stricture),  5  others  were 
living  at  periods  of  from  one  to  seven  months.  4  other  cases  were  claimed 
as  recoveries,  but  all  of  these  died  within  a  few  weeks  or  months  from  the 
operation  of  recurrence  or  marasmus.  In  the  remaining  11  (50  per  cent.) 
the  operation  may  be  credited  with  having  greatly  hastened  the  patient's 
death.    A  certain  number  of  unsuccessful  gastro- enterostomies  which  have 


SURGERY. 


549 


been  published  in  America  and  England  are  not  included — in  fact,  could  the 
real  truth  be  known  the  statistics  of  this  operation  would  probably  be  con- 
siderably worse  than  Dr.  Rockwitz  makes  them  appear. 

Two  cases  of  successful  abdominal  section  for  acute  intestinal  obstruction 
are  reported  in  the  British  Medical  Journal  of  May  21,  1887.  In  the  first  (by 
Mr.  Williamson,  of  Newcastle)  several  adhesions  and  two  constricting 
bands  were  liberated,  in  the  second  (by  C.  Stonham),  recent  peritonitis  was 
found,  and  the  obstruction  was  believed  to  be  due  to  a  volvulus  of  the  small 
intestine  which  was  untwisted  at  the  time  of  operation. 

The  value  of  Kussmaul's  plan  of  washing  out  the  stomach  in  cases  of 
operation  for  strangulated  hernia  and  intestinal  obstruction  is  warmly  endorsed 
by  Dr.  Rehn  (Centralblatt  fur  Chirurgie,  July  23,  1887),  who  observed  its 
effects  whilst  the  operation  was  in  progress  and  the  abdominal  cavity  opened. 
The  two  cases  (obstruction  hernia  and  obstruction  from  a  diverticulum  band), 
unfortunately,  ended  fatally,  but  the  relief  of  distention,  both  of  the  stomach 
and  intestine  by  the  washing  out,  was  extremely  marked  and  greatly  facilitated 
the  operations. 

The  Treatment  of  Intussusception. 

Mr.  Barker  [Lancet,  May  14,  1887)  in  a  case  of  intussusception  of  the 
rectum,  due  to  adenoid  epithelioma  of  that  part  of  the  gut,  succeeded  in 
drawing  down  and  excising  the  whole  of  the  affected  area  after  returning  the 
two  layers  of  intestinal  wall  together.  The  patient  made  a  good  recovery. 
Three  similar  cases  had  been  previously  operated  on  (two  by  Verneuil,  and 
one  by  Hulenkampff),  only  one  of  them  recovering. 

A  fatal  case  of  abdominal  section  for  intussusception  in  a  child  was  reported 
by  Mr.  Dent  in  the  Lancet  of  May  21,  1887.  The  bowel  was  reduced  with 
some  difficulty,  but  peritonitis  had  set  in  before  the  operation.  A  similar 
case  is  recorded  by  Mr.  Knaggs  in  the  Lancet  of  June  4  and  11,  1887, 
and  the  risk  attending  forcible  inflation  illustrated  by  the  quotation  of  eight 
cases  in  which  it  led  to  rupture  of  the  intestine.  Mr.  Knaggs's  paper  includes 
a  summary  of  eight  successful  abdominal  sections  for  intussusception  and 
twenty-nine  unsuccessful  ones.  Although  this  list  includes  several  not  pre- 
viously published,  it  is  probably  far  from  complete.  The  writer  strongly 
endorses  Mr.  Trever's  teaching  as  to  the  advisability  of  early  operation  if 
inflation  fail  to  relieve. 

Resections  and  Amputations. 

Dumont  (Archiv  fiir  hlinische  Chirurgie,  Bd.  xxxiv.,  Heft  2,  p.  318)  reports 
five  cases  of  resection  of  the  ankle-joint  (including  in  one  case  removal  of 
the  astragalus  and  part  of  the  os  calcis)  successfully  carried  out  by  a  single 
external  incision,  convex  downward.  All  the  patients  recovered  with  useful 
limbs. 

Feactures  and  Dislocations. 

The  occurrence  of  a  true  intertrochanteric  fracture  of  the  femur  and  the 
possibility  of  its  exact  diagnosis  during  life  was  proved  by  a  case  under  M. 
Hennequin,  recorded  in  the  Bull,  de  la  Soc.  Anat.  for  July,  1887.  Such 


550 


PROGRESS  OF   MEDICAL  SCIENCE. 


fractures,  detaching  the  head  and  great  trochanter  from  the  rest  of  the  bone, 
are  distinguished  from  ordinary  extracapsular  fractures  by  the  non-impaction, 
and  from  fracture  below  the  trochanters  by  noting  the  exact  level  of  the  angle 
of  bone  below  Poupart's  ligament,  but  it  is  obvious  that  the  latter  is  a  very 
difficult  point  of  diagnosis. 

Charcot's  Joint  Disease. 

Prof.  Sonnenbtjrg-  introduced  a  discussion  on  this  subject  at  the  German 
Congress  of  1887  ( Centralblatt  fur  Chirurgie,  No.  25).  Whilst  various  opinions 
were  held  as  to  the  pathology  of  the  disease,  nothing  positive  appears  to  have 
been  added  to  our  knowledge;  however,  a  novel  method  of  treatment  was 
illustrated  by  specimens  from  four  cases  in  which  the  affected  joint  had  been 
excised.  Although  the  results  of  the  operation  seem  to  have  been  fairly  good, 
it  may  be  doubted  whether  (considering  the  advanced  age  of  the  patients)  a 
severe  operation  like  excision  is  warranted  in  cases  of  joint  disease  from  ataxia. 

Prof.  Westphal  (Ibid,,  May  28,  1887)  has  traced  degeneration  of  nerves 
in  a  case  of  Charcot's  disease  into  the  small  branches  entering  the  joints,  as 
well  as  into  the  one  running  with  the  nutrient  artery  piercing  the  tibia. 
Jurgens  (Ibid.)  states  that  he  has  found  pathological  changes  (relaxation  of 
ligaments  and  congestion)  in  all  the  large  joints  from  cases  of  tabes,  but  that 
similar  changes  were  also  noticed  in  certain  cases  of  mental  disease,  chorea, 
etc. 

Operations  on  the  Kidneys  and  Bladder. 

A.  Edel  reports  in  the  Archiv  fur  Min.  Chir.,  Bd.  xxxiv!  p.  423,  a  case  of 
nephrectomy  for  renal  suppuration,  presenting  unusual  complications.  The 
patient,  a  man  aged  thirty-nine,  had  for  many  years  suffered  from  renal  colic, 
and  finally  presented  the  symptoms  of  localized  peritonitis  on  the  left  side, 
leading  to  an  abscess  in  the  inguinal  region  and  scrotum.  This  was  drained, 
but  was  followed  by  an  abscess  in  the  lung,  and  the  pus  became  urinous. 
Nephrectomy,  with  free  drainage,  was  followed  by  temporary  improvement, 
but  then  the  case  relapsed,  and  further  exploration  led  to  the  discovery  of  a 
third  abscess,  under  the  diaphragm,  communicating,  like  the  others,  with  the 
suppurating  kidney.  Ultimately,  the  cavity  granulated  up,  and  the  patient 
recovered. 

Koch,  in  Brun,s  Beitrage  zur  Min.  Chir.,  Bd.  ii.  Heft  3,  records  three  cases 
of  removal  of  vesical  papilloma,  two  by  the  suprapubic  incision,  one  after 
dilatation  of  the  urethra  (in  a  woman).  The  latter  presented  a  recurrence  at 
the  end  of  two  years ;  the  other  two  remained  well.  Koch  recommends  a 
perineal  cystotomy  in  cases  of  doubtful  diagnosis,  but  wisely  claims  for  the 
suprapubic  operation  alone  the  means  of  effecting  a  radical  removal  of  the 
tumor.  A  good  analysis  of  symptoms  and  record  of  previous  cases  is  appended 
to  the  paper. 

E.  de  Paoli  (Turin  Medical  Journal)  also  reports  a  successful  case  of 
removal  of  a  villous  growth  from  the  female  bladder  by  the  "  high  method," 
after  the  diagnosis  had  been  completed  by  dilatation  of  the  urethra. 

The  question  of  suprapubic  lithotomy  in  children,  was  dealt  with  by  F. 
Bereskin,  of  Moscow,  at  this  year's  Russian  Congress  (Centralblatt  fur  Chir., 
No.  22,  1887).    59  operations  resulted  in  8  deaths,  though  only  3  could  be 


SURGERY. 


551 


directly  assigned  to  the  operation  ;  of  26  cases  in  children  over  five  years,  only 
one  died  (of  scarlet  fever).  According  to  the  Moscow  Hospital  experience,  the 
mortality  of  the  suprapubic  method,  in  young  subjects,  was  actually  less  than 
that  attending  the  lateral  operation.  In  two  cases  the  peritoneum  was 
wounded  without  bad  effect. 

Considerable  discussion  was  held  at  the  above  Congress  on  the  various 
operations  for  stone,  but  the  conclusions  arrived  at  differed  but  little  from 
those  of  western  authorities,  the  great  advantages  of  litholapaxy  being  fully 
recognized,  and  suprapubic  lithotomy  again  returning  into  favor. 

M.  Terrier  {Societie  de  Chirurgie  Bull.,  April,  1887)  advocates  transperi- 
toneal nephrectomy,  with  suture  of  the  wound-edge  to  the  margin  of  the 
peritoneal  wound,  so  as  to  shut  off  the  space  left  by  the  removal  of  the  dis- 
eased kidney  from  the  general  peritoneal  cavity.  Two  cases  are  recorded 
(one  fatal),  the  incision  being  made  either  in  the  median  line  or  the  linea 
semilunaris.  Lumbar  drainage  is  dispensed  with,  although  it  is  evident  that 
the  assistance  of  gravity  is  thus  lost. 

An  unusual  complication  of  suprapubic  lithotomy — severe  hemorrhage  into 
the  bladder  some  days  after  the  operation — was  reported  by  Mr.  Morgan  in 
the  Lancet  of  May  7, 1887.  The  patient,  a  boy  of  six  years,  wejit  on  well  until 
the  fourth  day,  when  hemorrhage  occurred  into  the  bladder  and  the  tissues 
of  the  groin.  After  the  clot  had  been  washed  away  through  a  catheter  he 
made  a  good  recovery.  The  vesical  wound  had  been  sutured  with  catgut  and 
a  catheter  left  in  for  two  days,  the  latter  produced  nephritis,  and  was  removed. 
Mr.  Morgan  attributed  the  subsequent  hemorrhage  to  distention  of  the  bladder, 
owing  to  nephritis,  and  hence  condemns  the  retention  of  the  catheter  after 
the  operation,  at  any  rate  in  children. 

Mr.  Whitehead  {Lancet,  June  18, 1887)  reserves  suprapubic  lithotomy  for 
cases  unsuitable  for  either  lithotrity  or  the  lateral  operation,  he  reports  three 
cases  in  adults,  one  for  encysted  calculus,  a  second  for  a  large  stone  (7J// 
in  circumference),  the  third  is  a  case  in  which  no  staff  could  be  introduced. 
Two  ended  fatally  from  pyaemia  and  pneumonia,  the  third  only  recovered 
after  a  protracted  and  dangerous  illness.  It  was  found  to  be  extremely  diffi- 
cult to  recognize  and  open  the  bladder  in  two  of  the  cases;  in  fact,  in  one  the 
opening  was  deferred  for  a  week.  Rectal  distention  Mr.  Whitehead  regards 
as  unnecessary  and  dangerous,  it  having  been  followed  in  the  first  case  by 
severe  hemorrhage  and  muco-purulent  discharge. 

It  would  be  difficult  to  imagine  a  more  unfavorable  case  for  any  form  of 
operation  than  the  one  reported  by  Mr.  Harrison  [Lancet,  June  18,  1887). 
The  patient,  a  man  aged  fifty-six,  of  very  feeble  condition,  had  a  long  and 
tight  stricture,  a  false  passage,  calculi  in  both  bladder  and  urethra,  with  incon- 
tinence of  urine.  The  stricture  was  divulsed  so  that  a  staff  could  be  passed, 
on  this  the  floor  of  the  urethra  was  freely  divided,  a  calculus  removed,  and  then, 
with  the  finger  as  a  guide,  the  prostate  was  incised  along  its  floor  with  a  curved 
bistoury.  Two  calculi  were  now  removed  from  the  bladder,  and  a  drainage 
tube  left  in  the  wound  for  three  days.  Apart  from  the  fact  that  the  perineal 
opening  would  probably  be  permanent,  the  patient  made  a  very  good  recovery. 
In  advocating  for  certain  cases  a  median  lithotomy,  with  free  division  of  the 
prostatic  urethra,  Mr.  Harrison  in  no  way  dissuades  from  the  lateral  opera- 
tion, which  he  has  performed  over  a  hundred  times.    At  the  same  time  he 


552 


PKOGRESS  OF   MEDICAL  SCIENCE. 


claims  for  his  modification  (which  was  employed  by  Frere  Come  in  the  last 
century)  that  it  assimilates  the  median  to  the  lateral  operation  in  many 
respects,  whilst  being  free  from  the  risks  of  hemorrhage,  and  of  bruising  the 
prostatic  tissues.  Whether  any  permanent  injury  to  the  ejaculatory  ducts,  etc., 
is  liable  to  follow,  must  at  present  remain  an  open  question ;  nor  is  it  certain 
that  the  operation  would  be  free  from  the  subsequent  occurrence  of  inconti- 
nence of  urine,  which  is  such  a  distressing  sequence  of  lateral  lithotomy,  and 
one  more  common  than  is,  perhaps,  generally  believed. 

A  fatal  case  of  suprapubic  lithotomy  in  a  child  was  reported  by  Me. 
Greenwood  [Lancet,  June  11,  1887).  The  case  went  on  well  for  nearly  three 
weeks,  and  then  died  suddenly,  no  cause  being  found  at  the  post-mortem 
examination.  Isolated  cases  of  this  operation  will  be  found  in  the  British 
MedicalJournal  of  July  16, 1887  (adult  female,  good  result).  The  samejournal 
for  July  2,  1887  (child  aged  nine,  recovery  from  operation,  but  death  six 
months  later  from  broncho-pneumonia) ;  British  Medical  Journal  of  June  18, 
1887  (lad  aged  nineteen,  bladder  wound  sutured,  no  urine  escaped  through  it 
subsequently). 

Two  further  cases  of  vesical  papilloma  removed  through  a  suprapubic 
incision,  are  reported  by  Sir  Henry  Thompson  {British  Medical  Journal, 
June  11, 1887),  both  with  a  successful  result.  In  one  the  diagnosis  was  effected 
through  the  discovery  of  typical  papillomatous  fragments  in  the  urine,  in  the 
other  by  a  perineal  exploratory  operation.  The  writer  points  out  that  in  cases 
of  non-malignant  vesical  growth,  painless  intermittent  attacks  of  hemorrhage 
are  among  the  earliest  symptoms,  then  frequent  micturition  comes  on,  and 
finally,  more  or  less  continuous  bleeding.  As  regards  the  operation,  he  is 
not  in  favor  of  suturing  the  bladder  wound,  but  closes  the  greater  part  of  the 
abdominal  one,  leaving  a  tube  in  the  lower  part  for  two  or  three  days. 

Mr.  Edmund  Owen  [Lancet,  June  25,  1887)  reports  a  successful  case  of 
abdominal  nephrectomy  for  cystic  disease  of  the  kidney,  no  drainage  tube 
being  used. 

Mr.  Imlach  {Brit.  Med.  Journal,  July  2,  1887)  performed  abdominal  sec- 
tion for  what  was  suspected  to  be  an  ovarian  tumor;  it  proved  to  be  a  case  of 
hydatid  cyst  of  the  left  kidney.  After  removal  of  the  daughter-cysts  the  main 
one  was  sutured  to  the  edges  of  the  abdominal  wall  and  free  drainage  provided 
for.    The  patient  made  a  good  recovery. 

Mr.  E.  J.  Godlee  reported  to  the  Clinical  Society  {Brit.  Med.  Journal,  May 
21,  1887)  a  case  of  nephrectomy  in  a  child  after  rupture  of  an  ureter  and  sub- 
sequent formation  of  a  cyst  containing  urine.  The  case  did  well  but  for  the 
fact  that  a  sinus  still  remained.  In  another  case  a  large  cyst  developed  in 
the  abdomen  of  a  boy  after  a  severe  injury ;  it  was  opened  in  the  middle  line, 
the  walls  sutured  to  the  edges  of  the  abdominal  wound,  a  good  recovery  ensuing. 
In  a  third  case  a  cyst  in  one  lumbar  region  (also  after  injury)  was  tapped 
through  the  seventh  intercostal  space.  The  fluid  in  both  these  cases  contained 
urea,  in  one  to  a  large  amount,  but  it  was  pointed  out  in  the  subsequent  dis- 
cussion that  this  faot  did  not  suffice  to  assign  the  cysts  to  a  renal  origin. 

Tumors. 

The  'idea  that  the  infective  properties  of  new  growths  might  be  due  to 
microorganisms  has  naturally,  of  late,  attracted  some  pathologists,  but  the 


SURGERY. 


553 


series  of  experiments  by  Messrs.  Shattock  and  Ballance  {Path.  Society, 
May  17, 1887)  give  no  support  to  this  view.  Using  various  nutrient  materials* 
pieces  of  sarcoma,  epithelioma,  etc.,  were  "  cultivated,"  but  the  results  were 
entirely  negative.  It  was  incidentally  confirmed  by  the  investigators  that 
the  normal  tissues  of  the  viscera  are  wholly  free  from  microorganisms,  so  long 
as  care  is  taken,  in  experimenting,  to  exclude  accidental  contamination. 

Three  elaborate  papers  on  tumors  are  to  be  found  in  the  Deutsche  ZeiUchrift 
fur  Chirurgie,  Band  25,  Heft  4  and  5.  The  first,  by  Dr.  Fischer,  records  a 
case  of  primary  melanosis  of  the  penis,  and  goes  fully  into  the  literature  of 
the  subject.  The  second,  on  the  prognosis,  etc.,  of  scirrhus  of  the  breast,  by 
Dr.  Hildebrand,  is  a  valuable  contribution  to  the  statistics  of  the  operation 
of  excision.  The  third,  by  Dr.  Wassermann,  treats  of  the  various  sarcomata, 
or  "connective-tissue  growths''  met  with  about  the  head,  being  founded  on  a 
large  number  of  cases  observed  at  the  Heidelberg  clinic.  In  the  Archiv  fur 
klinische  Chirurgie,  Band  35,  Heft  2,  is  another  careful  compilation  of  cases  of 
melanotic  sarcomata  occurring  in  various  parts  of  the  body.  Although  hardly 
of  a  nature  to  allow  of  abstracting,  these  monographs  can  be  warmly  recom- 
mended to  those  interested  in  the  subject  of  malignant  growths. 

Operations  on  the  Gall-bladder,  etc. 

Mr.  Page  [Lancet,  June  25,  1885)  performed  cholecystotomy  in  a  case  of 
distended  gall-bladder ;  a  calculus  was  removed  from  the  cystic  duct  with 
lithotomy  forceps,  as  well  as  two  smaller  ones.  The  walls  of  the  cyst  were 
stitched  to  the  wound-edges  and  a  drainage  tube  inserted,  the  wound  entirely 
closing  in  five  weeks. 

Dupuytren's  Contraction. 

Prof.  Kocher  makes  an  interesting  contribution  to  the  study  of  this  dis- 
ease in  the  Centralblatt fur  Chirurgie  for  June  25  and  July  2, 1887.  Four  cases 
treated  by  simple  incision  of  the  affected  part  of  the  palmar  fascia,  after  fully 
cupping  it  by  Esmarch's  bloodless  method,  are  given  in  detail.  The  results 
were  very  satisfactory,  and  tended  to  disprove  the  view  held  by  some  that  the 
skin  is  concerned  in  the  production  of  the  deformity.  Primary  union  of  the 
wound  followed  in  three  of  the  four  cases,  no  drainage  being  provided  for.  A 
detailed  examination  of  the  incised  pieces  of  aponeurosis  showed  that  there 
was  a  cellular  thickening  in  the  vessel-walls,  together  with  multiplication  of 
the  connective-tissue  cells — in  short,  that  the  process  was  one  of  a  diffuse 
chronic  inflammatory  nature.  Whether  there  was  any  cell-exudation  or  not 
was  considered  doubtful.  The  family  tendency  toward  Dupuytren's  contrac- 
tion was  well  illustrated  by  one  case,  the  patient's  brother,  father,  and  one  uncle 
having  all  been  affected  in  the  same  manner. 

Diseases  of  the  Jaws. 

In  a  series  of  lectures  published  in  detail  with  illustrations  in  the  British 
Medical  Journal  for  June  and  July,  1887,  Mr.  Christopher  Heath  deals 
with  a  subject  of  which  he  has  long  made  a  special  study.  The  various 
tumors  affecting  the  maxillie  and  the  deformities  of  the  mouth  are  fully  de- 


554 


PEOGEESS  OF   MEDICAL  SCIENCE. 


scribed,  and  the  operations  for  their  relief  illustrated  by  a  number  of  cases. 
To  those  interested  in  the  subject,  Mr.  Heath's  lectures  will  be  found  to  con- 
tain much  valuable  material. 

Mercurial  Injections  in  Syphilis. 

M.  Martineau's  communication  on  this  subject  deserves  attention  owing 
to  his  very  large  experience,  for  he  has  since  1881  treated  no  less  than  six 
thousand  patients  by  this  method — i.  e.,  the  injection  of  a  peptonate  of  mer- 
cury into  the  back.  Each  patient  on  an  average  received  thirty  injections, 
and  subsequently  underwent  a  short  course  of  mercury  taken  by  the  mouth. 
According  to  the  author,  the  injection  plan  is  by  far  the  most  rapid  in  its  re- 
sults, and  is  practically  free  from  any  risk  of  causing  stomatitis,  etc. 

"  Hammer-toe." 

A  discussion  on  the  curious  deformity  of  the  first  interphalangeal  joint 
known  as  "hammer-toe"  took  place  at  the  Clinical  Society  (see  British  Med. 
Journal,  June  4,  1887).  Mr.  Anderson  showed  a  case  in  which  he  had  in- 
cised the  head  of  the  proximal  bone  with  good  result.  The  tendency  of  the 
deformity  to  occur  in  families  was  emphasized,  and  its  pathology  ascribed  to 
contraction  of  the  plantar  fibres  of  the  lateral  ligaments  and  of  the  glenoid 
plates.  In  a  debate  on  the  same  subject  at  the  Soci6te  de  Chirurgie  {Bulletin, 
April,  1887)  MM.  Terrier,  Verneuil,  and  Lannelongue  advocated  inci- 
sion of  the  affected  joint  in  preference  to  amputation.  There  is  no  doubt, 
whatever  view  be  held  as  to  the  pathology,  that  tenotomy  of  the  flexor  tendon 
is  quite  useless. 

Several  writers  (Messrs.  Howard,  Marsh,  Lucy)  have  lately  called  at- 
tention in  the  British  Med.  Journal  for  May,  to  a  chronic  form  of  arthritis 
affecting  the  great  toe-joint  (metatarso-phalangeal),  and  occurring  almost  ex- 
clusively in  young  men.  It  produces  considerable  pain  and  rigidity  in  the 
joint,  and  tends  to  gradual  recovery  with  some  stiffening.  Whilst  nothing 
very  new  was  brought  out  in  the  discussion  as  to  the  pathology  or  treatment, 
it  was  shown  that  many  of  the  cases  are  coincident  with  flat-foot,  others,  per- 
haps, being  due  to  inherited  tendency  to  joint-disease. 

Cleft  Palate. 

M.  Le  Bec  ( Gaz.  des  Hopitaux,  April  26,  1887)  in  a  case  of  cleft  palate  with 
wide  aperture  performed  an  operation  advised  by  M.  Lannelongue,  detaching 
a  flap  from  the  side  of  the  vomer  and  bringing  it  down  to  the  palate.  The 
result  was  not  encouraging,  owing  to  the  extreme  retraction  of  the  flap,  and 
would  not  appear  to  be  worth  imitation. 

Long  papers  on  the  anatomy  of  cleft  palate  have  appeared  in  the  recent 
numbers  of  the  Bulletin  de  la  Soc.  Anatomique.  The  author,  M.  Broca,  has 
examined  a  large  number  of  specimens  with  reference  to  the  doubt  lately 
thrown  by  M.  Albrecht  on  views  first  suggested  by  Groethe.  He  confirms  M. 
Albrecht's  observations  that  in  a  considerable  proportion  the  cleft  does  not 
pass  between  the  incisors  and  canine  teeth,  although  in  some  it  does.  Further, 
there  are  frequently  three  incisors  developed  on  one  or  both  sides,  and  the 
cleft,  if  present,  will  probably  pass  between  the  two  central  and  the  lateral 


SURGERY. 


555 


incisor.  M.  Broca's  work  is  very  detailed,  but  unfortunately  is  poorly  illus- 
trated. 

Another  contribution  to  the  subject  of  "  Cleft  Palate  and  Fissures  of  the 
Face"  is  by  Dr.  Morian  in  the  Archiv  fur  Minische  Chirurgie,  Band  35, 
Heft  2.    It  is,  however,  of  purely  pathological  interest. 

Synovial  Cysts  in  the  Neighborhood  of  the  Knee. 

A  case  of  multiple  cysts  on  all  sides  of  the  knee-joint  in  a  man  of  fifty- 
three  of  rheumatic  tendencies,  is  reported  by  Mr.  Mayo  Kobson  in  the 
Lancet  of  July  16,  1887.  M.  Poinier  has  been  investigating  the  subject  and 
has  from  a  large  number  of  specimens  arrived  at  the  conclusion,  that  in  prac- 
tically every  case  the  cysts  owe  their  origin  to  distention  of  diverticula  from 
the  joint.  Sometimes  they  become  shut  off  from  the  articulation,  but  careful 
dissection  will  even  then  reveal  traces  of  the  previous  communication.  M. 
Poinier's  papers  are  to  be  found  in  the  recent  numbers  of  Bull,  de  la  Soc.  Ana- 
tomique.  Mr.  Morrant  Baker  has  arrived  at  much  the  same  conclusions, 
and  both  writers  attribute  to  rheumatic  arthritis  a  large  share  in  the  produc- 
tion of  the  diverticula. 

Surgical  Dressings. 

Von  Mosetig  Moorhof  strongly  recommends  an  occlusive  dressing  of 
iodoform  gauze  and  wool  in  the  case  of  burns  and  scalds,  gutta-percha  tissue 
being  applied  astride  the  iodoform  dressing.  Under  favorable  circumstances 
the  dressing  may  be  left  for  a  week  or  more  before  changing  it;  whilst  in 
other  cases  it  is  best  to  apply  fresh  iodoform-vaseline  daily.  He  has  not  seen 
any  toxic  effects — but  the  possibility  of  their  occurrence  should  be  borne  in 
mind. —  Wiener  med.  Presse,  1887,  Nos.  2  and  3. 

De  Rtjyter  (German  Surgical  Congress,  1887),  Senger  and  others  have 
to  a  certain  extent  vindicated  the  antiseptic  properties  of  iodoform  from  the 
recent  attacks  of  Danish  investigators  (Heyn  and  Eovsing  in  the  Fortschritte 
der  Medicin).  Whilst  confirming  the  fact  that  iodoform  has  practically  no 
action  on  germ-life,  etc.,  outside  the  body,  De  Euyter  showed  that  in  the 
presence  of  ptomaines  the  drug  is  decomposed  and  has  a  powerful  antiseptic 
effect.  Prof.  P.  Bruns  [Ibid)  has  treated  over  fifty  cases  of  cold  abscess 
with  iodoform  injections  (ten  per  cent,  of  iodoform  mixed  with  equal  parts  of 
alcohol  and  glycerine)  and  speaks  as  favorably  of  the  method  as  does  M.  Ver- 
neuil,  of  Paris.  He  claims  for  the  drug  a  direct  effect  upon  the  tubercle- 
bacilli. 

A  New  Operating  Table. 

Dr.  Hagedorn,  of  Magdeburg,  to  whom  the  profession  is  already  indebted 
for  introducing  several  improvements  in  surgical  instruments,  has  lately  de- 
vised an  operating  table  especially  adapted  for  antiseptic  irrigation  during  the 
course  of  the  operation.  It  is  figured  and  described  in  the  Centra Iblatt  fur 
Chirurgie,  July  9,  1887,  and  its  chief  feature  is  a  median  gutter  or  trench, 
toward  which  on  either  side  the  surface  of  the  table  is  made  to  slope.  The 
table  is  covered  with  India-rubber,  and  the  fluid  running  into  the  trench  is 


556 


PKOGRESS  OF   MEDICAL  SCIENCE. 


conveyed  by  a  pipe  into  a  vessel  placed  beneath.  The  ease  with  which  the 
whole  can  be  disinfected  is  an  obvious  recommendation. 

Injuries  of  Nerves. 
Mr.  A.  Bowlby  {Lancet,  May  and  June,  1887),  in  an  interesting  course  of 
lectures  at  the  Eoyal  College  of  Surgeons,  described  the  pathology  and  treat- 
ment of  injuries  to  nerves,  and  the  modes  of  reunion.  They  should  be  con- 
sulted as  giving  a  full  account  of  the  present  state  of  our  knowledge  on  the 
subject.  Mr.  Bowlby  supported  the  "  trophic  influence  "  view,  gave  examples 
of  rapid  restoration  of  function  after  primary  reunion  of  nerves  (an  interest- 
ing case  of  which,  reported  by  M.  Polaillon,  was  discussed  at  the  Societe 
de  Chirurgie  on  May  25,  and  June  10,  1887),  and  went  fully  into  the  subject 
of  "  supplementary  sensation  "  after  division  of  a  nerve  due  to  communication 
of  its  branches  with  those  of  adjoining  nerves. 

Mycosis  Fungoides. 

According  to  some  writers  on  this  rare  disease  some  cases  are  capable  of 
complete  absorption  or  resolution  of  the  new-growth,  thus  sharply  distin- 
guishing the  latter  from  the  class  of  sarcomata.  H.  Hobner  [Deutsche 
medicinische  Wochenschrift,  1886,  Nos.  39  and  40)  describes  one  case  in  which 
the  multiple  tumors  disappeared  under  arsenical  treatment,  he  also  gives 
another  in  which  the  usual  fatal  result  followed  from  pneumonia  and  nephri- 
tis. Very  careful  research  for  a  microorganism  in  the  new-growths  or  the 
viscera  was  attended  with  only  negative  results.  According  to  Hochsinger 
and  Schife  ( Vierteljahrschrift  fur  Dermal,  und  Syphilis,  1886,  p.  361),  who 
report  a  third  case,  streptococci  were  found  in  the  vessels,  but  their  significance 
appear  doubtful. 

Four  stages  are  described  in  the  course  of  this  peculiar  disease :  1,  erythe- 
matous or  eczematous  patches  on  the  skin ;  2,  small  lichenoid  elevations ;  3, 
large  moist  tuberous  elevations ;   and  4,  general  cachexia. 

Diseases  of  the  Bectum. 

The  usual  treatment  of  stricture  of  the  rectum  by  dilatation  is,  as  a  rule, 
so  painful  and  often  so  unsatisfactory  that  were  electrolysis  an  efficient  sub- 
stitute it  would  be  gladly  welcomed.  The  case  recorded  by  Mr.  Whitehead 
(British  Medical  Journal,  July  2,  1887)  is  not  very  encouraging,  as  after  a 
thorough  trial  of  electrolysis  the  stricture  was  found  to  be  as  tight  as  before. 
It  may  be  mentioned  that  Mr.  Whitehead  discredits  the  theory  of  the  origin 
of  fibrous  stricture  of  the  rectum  from  pelvic  cellulitis  or  injury  in  childbirth, 
and  believes  that  it  is  nearly  always  due  to  a  venereal  cause. 

(ESOPHAGOTOMY. 

Dr.  G.  Fischer  records  the  successful  removal  of  an  eyeglass  which  had 
become  impacted  just  below  the  cricoid  cartilage,  the  patient,  a  young  man 
of  sixteen.  The  use  of  forceps  was  unavailing,  so  the  oesophagus  was  opened 
on  the  left  side  in  the  usual  manner.  The  wound  in  it  was  closed  with  catgut, 


SURGERY. 


557 


an  India-rubber  tube  employed  for  giving  fluid  food,  and  the  progress  was  one 
of  uninterrupted  recovery.  An  analysis  of  eighty  recorded  cases  (sixty  suc- 
cessful) of  cesophagotomy  for  foreign  bodies  is  appended.  Another  is  added 
by  Mr.  Bennett  May,  in  the  British  Medical  Journal  for  May  21,  1887,  and 
presents  several  points  of  interest.  A  child,  aged  four  years,  had  swallowed 
a  half  penny  which  remained  impacted  just  below  the  top  of  the  sternum  for 
three  years,  during  which  time  he  had  become  so  emaciated  from  dysphagia 
as  to  be  unfit  for  any  operation.  By  means  of  a  catheter,  which  was  intro- 
duced past  the  obstruction  with  much  difficulty,  fluid  nutriment  was  conveyed 
into  the  stomach,  and  as  soon  as  his  general  condition  had  sufficiently  im- 
proved cesophagotomy  was  performed  in  the  usual  manner.  Considerable 
force  was  required  to  remove  the  coin,  and  a  rush  of  air  showed  that  a  com- 
munication existed  with  the  trachea  or  a  bronchus.  Nutrient  enemata  were 
tried  for  four  days,  but  the  patient's  condition  then  compelled  a  resort  to 
feeding  by  the  oesophagus.  The  regurgitation  of  fluids  through  the  wound 
delayed  healing,  which,  however,  speedily  occurred  after  an  India-rubber  tube 
had  been  passed  through  the  mouth.  With  the  exception  of  an  attack  of 
intestinal  obstruction,  due  to  impacted  feces,  the  subsequent  recovery  was 
almost  uncomplicated. 

Hydatid  Cysts. 

A  singular  complication  of  an  hydatid  cyst  in  the  neck  occurred  in  a  girl 
under  the  care  of  Dr.  Gardner,  of  Adelaide  {Brit.  Med.  Journ.,  July  16, 
1887).  In  the  belief  that  the  tumor  was  composed  of  caseating  glands  it  was 
cut  down  upon,  and  after  evacuating  the  cyst  the  latter  was  found  to  extend 
downward  into  the  thorax.  Severe  hemorrhage  occurred  on  two  occasions 
subsequently,  proving  fatal.  The  subclavian  artery  was  found  to  be  eroded 
in  its  first  part,  so  that  the  vertebral  and  inferior  thyroid  arteries  were 
detached  from  the  main  trunk. 

Several  cases  of  severe  collapse  attending  the  aspiration  of  hydatid  cysts 
have  been  lately  recorded,  one  by  Dr.  Thomas,  of  Adelaide  {Brit.  Med. 
Journ.,  May  21, 1887).  In  this  case  the  cyst  was  large,  and  was  diagnosticated 
as  of  splenic  origin.  Only  three  ounces  were  withdrawn,  but  syncope  rapidly 
came  on,  and  lasted  several  hours.  The  patient  eventually  rallied  under  the 
hypodermatic  administration  of  ether.  It  seems  probable  that  in  such  cases 
the  absorption  of  a  poison  contained  in  the  cyst-fluid  accounts  for  the  symp- 
toms, although  it  is  well  known  that  similar  phenomena  occasionally  follow 
the  aspiration  of  simple  pleuritic  effusions. 

Hydrophobia. 

In  June,  of  this  year,  the  report  of  the  English  Commission  on  M.  Pasteur's 
method  of  inoculation  was  presented  to  the  House  of  Commons,  and,  speaking 
generally,  it  may  be  said  to  confirm  in  all  important  points  the  claims  made 
by  the  great  French  savant.  Experiments  made  on  animals  by  Mr.  Victor 
Horsley  showed  that  M.  Pasteur's  preventive  inoculations  provided  a  com- 
plete protection,  while  careful  analysis  of  the  cases  treated  in  Paris,  which 
was  made  by  Professsor  Sanderson  and  Dr.  Brunton,  pointed  strongly  to  a 
similar  protection  being  afforded  in  the  human  subject.    At  the  same  time 


558 


PROGRESS  OF   MEDICAL  SCIENCE. 


the  "  intensive  method"  appeared  to  have,  in  more  than  one  instance,  directly- 
led  to  a  fatal  issue,  and  M.  Pasteur  has  since  modified  this  form  of  inoculation. 
On  the  other  hand,  Prof,  von  Fritsch  {Die  Behandlung  der  WuthJcranJcheit,  etc., 
Vienna,  1887)  has,  after  a  careful  series  of  experiments  in  Paris  and  Vienna, 
failed  to  verify  M.Pasteur's  conclusions  in  several  important  respects.  Thus, 
in  rabbits  and  dogs,  submitted  to  subdural  infection  after  undergoing  a  series 
of  preventive  inoculations,  a  large  proportion,  if  not  all,  succumbed  to  rabies. 
Even  the  "  intensive  method"  was  of  no  avail  in  the  majority  of  instances. 
So  that,  at  present,  the  statements  of  Dr.  Fritsch  and  Mr.  Horsley  are  in  direct 
contradiction  with  each  other. 

The  following  papers  are  especially  worthy  of  notice  amongst  those  which 
have  been  published  during  the  last  three  months: 

Aero- Urethroscopy,  by  Dr.  G.  VON"  Antal  (Centralblatt  fur  Chir.,  May  14, 
1887).  By  means  of  India-rubber  bags  connected  with  the  endoscope  the 
urethra  is  distended  with  air  so  as  to  facilitate  the  examination  of  its  wall. 

Necrosis  of  the  Aural  Labyrinth  and  Paralysis  of  the  Facial  Nerve,  by  F.  Bi- 
zold  (Zeitschrift  fur  Ohrenheilkunde,  Band  xvi.).  Details  of  41  cases  are  given, 
28  complicated  by  facial  paralysis.  The  importance  of  removal  of  the 
sequestrum,  as  soon  as  practicable,  is  dwelt  upon,  and  the  various  symptoms 
dealt  with  in  detail.    Disturbances  of  equilibrium  are  rarely  observed. 

Case  of  Perforating  Ulcer  of  the  Duodenum,  by  A.  Dutil  {Bull,  de  la  Soc. 
Anat.,  July  1,  1887).  This  case  was  interesting  surgically,  inasmuch  as  the 
symptoms  closely  resembled  those  of  internal  strangulation. 

Study  of  the  Fractures  of  the  Upper  End  of  the  Humerus,  by  Dr.  Hennequin 
[Revue  de  Chirurgie,  June,  1887). 

Tertiary  Syphilitic  Affections  of  the  External  Genitals,  by  Ch.  Matjriac  ( An- 
nates de  derrnat.  et  syph.,  1887,  Nos.  1  and  2).  The  author  gives  details  of 
26  cases,  well  illustrating  the  difficulty  which  frequently  attends  their  diag- 
nosis from  primary  chancres,  etc. 

The  Treatment  of  Syphilis  by  Tannate  of  Mercury,  by  C.  Schadeck  [St.  Peters- 
burger  med.  Wochenschrift,  1887,  No.  6).  The  writer  does  not  claim  for  this 
drug  any  great  superiority  over  the  other  preparations  of  mercury,  but  states 
that,  as  a  rule,  it  is  less  liable  to  produce  salivation. 

Spina  Bifida  Occulta,  by  J.  B.  Sutton  (Lancet,  July  2,  1887).  A  short  lec- 
ture on  the  curious  overgrowth  of  hair  occurring  over  the  site  of  defective 
spinal  arches.  Six  examples  are  referred  to,  it  is  interesting  that  in  two  there 
was  a  "  perforating  ulcer  of  the  foot,"  and  clubfoot  has  also  been  noticed, 
although  there  is,  in  some  cases,  no  sign  of  the  abnormality  in  later  life  except 
hypertrichosis  (usually  in  the  lumbo-sacral  region). 

Case  of  Cerebral  Abscess  following  Empyema.  Unsuccessful  Trephining,  by  Dr. 
Drtjmmond  {Lancet,  July  2,  1887).  In  this  case  the  abscess  was  situated  in 
the  upper  part  of  the  ascending  frontal  lobe,  the  trephine  being  applied  over 
the  lower.    The  case  is  well  recorded,  and  merits  careful  perusal. 

Strangulated  Hernia  complicated  by  Suppurative  Peritonitis.  Operation.  Re- 
covery.   Dr.  J.  Bramwell  {Brit.  Med.  Journ.,  July  16,  1887). 

Incision  of  the  Larynx.  Dr.  Gardner,  of  Adelaide  {Lancet,  May  7,  1887). 
In  this  case,  one  of  epithelioma,  in  a  man  of  sixty  years,  the  operation  was 
recovered  from,  but  the  growth  returned  within  four  months. 


SURGERY. 


559 


The  Radical  Cure  of  Hernia  by  Injection,  by  C.  B.  Htjtley  {Brit.  Med.  Journ., 
May  21,  1887).  One  case  of  double  hernia,  operated  on  by  the  writer,  has 
proved  a  perfect  success,  having  stood  the  test  of  time ;  the  two  reported  in 
detail  only  showed  that,  although  severe  inflammatory  reaction  might  be  pro- 
duced by  the  injection  (decoction  of  oak-bark,  glycerite  of  tannic  acid,  etc.), 
no  curative  effect  was  produced  on  the  hernia. 


In  America. 


Exctsiox  of  the  Larynx  axd  Pharyxx. 

Dr.  D.  Hayes  Agxew  reports  in  The  Medical  News  of  April  9,  1887,  an 
operation  of  this  kind  on  a  man,  fifty-eight  years  old,  for  the  removal  of  a  sarco- 
matous growth  as  it  was  considered  before  operation,  but  which  proved  to  be 
a  tubular  epithelioma.  Eecognized  laryngoscopically  by  Drs.  J.  Solis  Cohen 
and  C.  Seiler  to  extend  down  to,  but  not  below  the  vocal  cords,  excision  of 
the  larynx  was  advised  and  performed  February  2,  1887,  at  the  University 
Hospital.  After  the  larynx  had  been  removed  the  pharynx  was  seen  to  be 
so  much  involved  as  to  demand  its  extirpation,  "saving  a  very  narrow  strip  of 
its  posterior  wall."  The  secretions  of  the  mouth  and  fauces  threatening  infil- 
tration of  the  mediastinum  by  working  through  the  loose  tracheal  fascia,  an 
aseptic  sponge  plug,  frequently  changed,  was  placed  in  the  fauces.  The 
trachea  was  plugged  with  a  perforated  rubber  cork,  "through  which  was 
passed  a  siphon  tube,"  its  outer  orifice  being  kept  covered  with  antiseptic 
gauze.  The  operation  was  antiseptic  throughout.  Death  occurred  on  the 
fourth  day,  but  owing  to  the  absence  of  a  post-mortem  examination  it  is 
doubtful  whether  this  result  was  due  to  heartTailure,  sepsis,  or  pneumonia. 
Should  he  perform  a  similar  operation  Dr.  Agnew  says  that  he  will  certainly 
make  a  preliminary  tracheotomy  some  time  before  excising  the  larynx. 

Middle  Mexixgeal  Hemorrhage— Treatment  by  Trephixing. 

Dr.  Charles  A.  Powers,  in  the  Medical  Record  of  June  24,  1887,  reports 
the  case  of  a  man  twenty-eight  years  of  age,  who,  brought  into  hospital 
thirty-six  hours  previously  in  a  comatose  condition,  had  regained  conscious- 
ness and  apparently  normal  motility,  but  presented  at  the  time  of  operation 
the  following  symptoms  : 

The  pulse  was  80,  respiration  18,  temperature  99°  ;  the  patient  was  perfectly 
rational.  There  was  complete  paralysis  and  anaesthesia  of  the  left  upper  ex- 
tremity, also  a  slight  degree  of  "  fluttering"  on  the  left  side  of  the  face.  The 
patient  said  he  did  not  feel  a  pin-prick  as  acutely  on  the  left  side  of  the  face 
as  he  did  on  the  right.  The  tongue  did  not  deviate ;  the  right  pupil  was  a 
little  larger  than  the  left ;  both  responded  to  light.  There  was  no  aphasia. 
The  scalp  in  the  occipital  and  the  back  part  of  the  right  parietal  region 
had  a  rather  "  pulpy  feel."  Serous  discharge  from  the  right  ear  continued, 
having  been  preceded  by  a  moderate  hemorrhage,  and  there  was  now  an  area 
of  ecchymosis  over  the  right  mastoid  region  about  the  size  of  a  silver  quarter. 


560 


PKOG-KESS  OF  MEDICAL  SCIENCE. 


After  locating  the  fissure  of  Eolando — by  an  unnecessarily  complex  method 
— a  free  crucial  incision  was  made  over  the  motor  area  of  the  arm  through  a 
"  markedly  congested"  scalp.  A  fissure  was  found  in  the  parietal  bone 
running  antero-posteriorly  three  inches  from  the  median  line  of  the  vertex, 
from  which  blood  oozed.  A  three-fourths  of  an  inch  trephine  crown  was 
applied  over  the  fissure,  at  a  point  where  a  line  drawn  from  the  commencement 
of  the  fissure  of  Rolando  to  the  external  auditory  meatus  would  intersect  the 
fissure  in  the  skull.  Beneath  the  perforation  was  found  a  clot ;  the  opening 
was  enlarged  by  the  rougeur  until  an  elliptical  opening  three  inches  long  and 
one  and  one-half  inches  wide  was  made.  The  clot  was  now  removed  by  a 
spoon-handle,  the  finger,  and  irrigation,  leaving  a  depression  one  and  three 
quarters  inches  at  its  deepest  part,  and  whose  superficial  area  measured  six  and 
one-fourth  inches  from  before  backward,  and  three  and  one-half  inches  from 
above  downward.  The  dura  mater  was  intact,  but  several  oozing  points  re- 
quired ligation.  The  cavity  was  irrigated  by  mercuric  bichloride  1  to  6000, 
and  to  facilitate  drainage  a  counter-opening  was  made  by  a  trephine-cut  at 
the  lowest  point  of  the  cavity,  viz.,  "just  above  the  point  where  the  lateral 
sinus  crosses  the  lambdoid  suture."  A  drainage  tube  passing  through  both 
openings,  a  moderate  packing  of  the  cavity  with  strips  of  iodoform  gauze  to 
check  oozing,  drainage  secured  by  placing  antiseptic  gauze  beneath  the  scalp 
wounds  at  all  points,  and  a  large  dressing  of  bichloride  gauze  and  borated 
cotton  applied  over  all,  completed  the  operation.  Strict  antiseptic  precautions 
were  taken.  * 

The  following  morning,  partial  return  of  power  and  sensation  was  detect- 
able in  the  upper  extremity  and  face :  the  gauze  packing  was  removed,  and 
the  dura  mater  was  found  "advanced  about  half  way  to  the  inner  surface  of 
the  skull."  The  following  day  the  dura  was  nearly  in  contact  with  the 
skull.  Within  forty-eight  hours  the  dura  mater  and  skull  had  reunited  (?) 
except  along  the  drainage  track  and  where  the  packing  was  left.  Accord- 
ingly, the  tube  was  withdrawn,  a  horse-hair  drain  substituted,  and  various 
symptoms  of  cerebral  irritation  of  no  special  moment  succeeding  one  another, 
but  with  a  temperature  never  over  101° — and  usually  much  less — on  the 
twenty-ninth  day  he  was  walking  about  the  ward;  "rational,  pulse  and 
temperature  normal,   ....    functions  of  left  arm  equal  to  those  of  right." 

The  remainder  of  the  paper  deals  with  the  literature  of  the  subject,  and 
the  diagnosis  and  methods  of  locating  extravasations. 

Trephining  in  a  Case  on  InteR-meningeal  Hematoma 
with  Hemiplegia. 

Dr.  S.  T.  Armstrong,  in  the  Journal  of  the  American  Medical  Association 
of  June  18, 1887,  reports  a  case  in  which,  nearly  two  months  after  a  blow  from 
the  corner  of  a  brick,  which  produced  a  lacerated  wound  half  an  inch  above 
the  external  edge  of  the  left  eyebrow  without  fracture  of  the  skull,  sudden 
slight  dragging  of  tne  right  foot  was  complained  of.  The  next  day,  while  at 
breakfast,  the  patient's  head  suddenly  fell  forward  on  the  table,  and  the  right 
arm  and  leg  seemed  paralyzed,  but  five  days  later,  only  some  dragging  of  the 
right  foot  and  occasional  loss  of  control  of  the  right  arm  and  leg  existed.  A 
roaring  sound  in  the  left  ear  persisted  from  the  time  of  injury,  and  hearing 


SURGEKY.  561 

was  deficient  on  this  side.  Two  days  later,  the  paretic  condition  of  the  leg 
was  more  marked  and  that  of  the  arm  slight,  but  constant  and  undoubted. 
Morning  chilliness  was  noted  from  the  time  of  the  first  hemiplegic  seizure. 

The  diagnosis  was  made  of  a  cortical  lesion  affecting  the  middle  frontal 
convolutions,  and  extending  upward  and  backward  gradually  involving  the 
ascending  frontal  convolution.  This  lesion  was  believed  to  be  a  septic  puru- 
lent inflammation.  Sixty-four  days  after  the  accident,  and  thirteen  from  the 
appearance  of  cerebral  symptoms,  double  optic  neuritis  being  present,  trephin- 
ing was  done  over  the  middle  frontal  convolution,  and  the  non-pulsatile, 
dark-colored  dura  mater  was  punctured  with  the  needle  of  a  large  hypoder- 
matic syringe,  upon  drawing  up  the  piston  of  which,  the  instrument  was 
filled  with  dark  brown  blood,  a  similar  fluid  flowed  from  the  needle  puncture, 
which  was  slightly  enlarged,  giving  vent  to  much  more  brownish  fluid  blood. 
Four  strands  of  aseptic  horsehair  were  passed  through  the  dural  opening,  and 
boracic  acid  applied  to  the  wound  with  absorbent  cotton  and  a  bandage.  By 
the  evening  of  the  day  of  operation  control  over  the  right  arm  and  leg  had 
been  regained.  On  the  eighth  day,  he  could  walk  with  "undiminished 
muscular  control,"  and  rapidly  recovered. 

In  regard  to  finding  blood  instead  of  pus,  this  corroborated  the  dictum  of 
Nancrede  {International  Cyclopaedia  of  Surgery,  vol.  v.  p.  50) :  "  A  differential 
diagnosis  can,  under  the  most  favorable  circumstances,  be  only  probable  and 
is  in  most  instances  impossible."  The  literature  of  the  subject  is  thoroughly 
reviewed.   

Laparotomy  for  Perforation  of  the  Appendix  Vermiformis. 

Dr.  R.  F.  Weir,  in  an  elaborate  paper  in  the  Medical  Record  of  June  11, 
1887,  treats  the  whole  subject  exhaustively.  Dr.  Weir  states  that  death  occurs 
within  the  first  five  days  in  34  per  cent,  of  adults  according  to  Fitz,  and  in 
70  per  cent,  of  children,  while  44  per  cent,  of  these  deaths  take  place  within 
the  first  three  days  according  to  Matherstock. 

In  consideration  of  these  data,  it  seems  to  him  justifiable  to  urge  the  neces- 
sity of  opening  all  inflammatory  swellings  of  the  right  iliac  region  as  early  as 
possible.  If  from  too  great  tenderness  palpation  is  interfered  with,  and  ex- 
ploration with  a  good-sized  aspirator  needle  carried  in  several  directions  into 
the  lumbar  region,  as  well  as  deep  into  the  iliac  fossa  reveals  no  pus,  anaes- 
thesia should  be  induced,  and  a  conjoined  abdominal  and  rectal  examination 
be  gently  made.  "If  a  tumor  be  made  out,  in  such  circumstances,  the  use  of 
an  exploratory  incision  running  as  if  for  ligature  of  the  external  iliac  artery, 
or,  .  .  .  one  starting  two  inches  in  front  of  the  longissimus  dorsi  muscle 
and  running  forward  just  above  the  iliac  crest,  can  be  resorted  to  until  the 
swelling  is  reached,  when  either  aspiration  can  again  be  used  or  the  tumor 
can  be  directly  incised."    The  author's  recapitulation  is  as  follows  : 

1.  That  the  generality  of  perityphlitic  abscesses  are  due  to  inflammation  or 
perforation  of  the  appendix  vermiformis. 

2.  That  the  mortality  in  such  lesions  is  greatest  prior  to  the  third  day. 

3.  That  as  soon  as  it  can  be  recognized,  pus  should  be  evacuated  extra- 
peritoneally,  if  possible,  or  by  a  lateral  laparotomy,  and  the  cavity  drained. 

4.  That  if  aspiration  fails  to  detect  pus  where  a  tumor  exists,  it  is  wiser  to 
make  an  early  extra-peritoneal  exploratory  incision. 

NO.  CLXXXVIII. — OCTOBER,  1887.  36 


562 


PHOGKESS  OF   MEDICAL  SCIENCE. 


5.  That  where  general  peritonitis  is  progressing  with  any  history  of  a  right 
iliac  pain,  a  limited  lateral  (preferable)  or  a  median  laparotomy  should  be 
made,  to  explore  the  region  of  the  appendix  within  forty-eight  hours  from 
the  inception  of  the  disease. 

6.  That  if  pus  is  thus  recognized,  it  should  be  evacuated  and  a  drainage 
tube  inserted  without  toilet  of  the  peritoneum. 

Laparotomy  for  Perforating  Pistol-shot  Wound  of  the  Abdomen. 

Dr.  J.  I.  Skelley,  in  the  Annals  of  Surgery  for  July,  1887,  reports  a  case 
in  which  after  section  no  wound  of  any  viscus  was  detected,  but  the  ball 
and  blood  having  been  removed,  and  a  bleeding  point  in  the  ball-track,  from 
which  blood  was  flowing  into  the  abdomen,  having  been  secured,  all  pain 
and  shock  ceased.  The  peritoneum,  linea  alba,  and  skin  were  separately 
sutured  with  catgut,  and  iodoform  used,  perfect  union  resulting  in  one  week's 
time.  There  was  no  rise  of  temperature  at  any  time.  Under  disadvantage- 
ous circumstances  strict  asepsis  was  secured,  and  the  important  surgical  fact 
demonstrated  that  even  without  visceral  penetration  laparotomy  is  the  best 
treatment  for  penetrating  abdominal  ball-wounds. 

Splenectomy. 

Dr.  J.  W.  Leonard  in  The  Medical  News  of  August  13,  1887,  reports  for 
the  operator,  Dr.  James  McCann,  a  case  of  this  rare  operation  upon  a  female 
patient,  set.  twenty-nine  years.  The  tumor  had  been  noticed  for  six  years, 
but  her  health  had  been  good  except  apparently  as  a  consequence  of  three 
miscarriages,  until  some  time  in  1882,  two  months  before  her  last  miscar- 
riage, when  she  had  her  first  attack  of  haematemesis,  followed  by  seven  others 
up  to  March,  1886,  inclusive.  These  attacks  came  on  with  great  suddenness, 
were  of  most  alarming  severity,  and  the  only  premonitory  symptoms  were 
drowsiness  and  general  malaise.  These  hemorrhages  were  only  arrested  by 
syncope,  until  the  patient,  on  her  admission  to  the  Pittsburg  Hospital,  on 
May  6,  1886,  presented  all  the  symptoms  of  most  profound  anaemia. 

Physical  exploration  of  the  abdomen  revealed  the  presence  of  an  extremely 
mobile  tumor  occupying  the  left  iliac,  and  extending  to  the  suprapubic  region. 
"  Its  surface  was  flat  and  smooth,  contour  well  defined,  of  oblong  or  roundish 
shape ;  dimensions  four  by  five  inches ;  consistency  more  than  semi-solid ; 
percussion  note  dull,  and  the  auscultatory  signs  were  negative." 

The  tumor  rapidly  increased  in  size  for  a  short  time  after  its  first  appear- 
ance, but  for  a  year  it  had  remained  stationary,  "  except  just  before  a  hemor- 
rhage, when  it  would  become  considerably  enlarged,"  and  then  would  pulsate 
violently.  There  was  abnormal  resonance  over  the  splenic  area.  After 
improvement  of  her  general  health  by  tonics,  etc.,  on  May  27,  1886,  median 
laparotomy  by  a  five  inch  incision  was  done,  and  the  spleen  was  removed  after 
separating  a  broad  and  firmly  adherent  portion  of  omentum.  During  these 
manipulations  the  spleen  was  ruptured,  resulting  in  profuse  hemorrhage, 
which  was  promptly  arrested  by  the  pressure  of  an  assistant's  hand.  Full 
Listerian  precautions  were  employed,  even  to  the  use  of  the  spray.  Although 
not  more  than  two  (?)  ounces  of  blood  was  lost,  the  most  profound  shock 
ensued,  but  reaction  took  place  after  numerous  hypodermatic  injections  of 


SURGERY. 


563 


ether  and  whiskey.  She  was  discharged  thirty-three  days  after  operation. 
Menstruation  returned,  and  persisted  until  she  became  pregnant,  in  October 
or  November,  1886. 

A  table  is  appended,  showing  all  the  complete  excisions  of  the  spleen  made 
since  1881,  the  date  of  Mr.  Collier's  paper — seventeen  in  all,  with  twelve 
recoveries.  The  reporter  is  sanguine  as  to  the  future  applicability  and  success 
of  this  operation,  "even  in  cases  of  hypertrophy  complicated  by  leukaemia." 

Suprapubic  Cystotomy. 

Dr.  F.  S.  Dennis,  in  the  Medical  News  of  May  28,  1887,  first  proves  that 
the  great  changes  in  operative  procedure  now  in  vogue,  have  been  brought 
about  by  dissections  and  experimental  work  on  the  cadaver.  The  modern 
operation  only  differs  from  that  of  the  sixteenth  century  in  the  perfection 
and  completeness  of  its  details.  Stress  is  laid  upon  the  additional  safeguard 
against  urinary  infiltration  offered  by  the  use  of  an  antiseptic  fluid,  instead 
of  ordinary  water,  for  distending  the  bladder.  Dr.  Dennis  contends  that  the 
old  suprapubic  operation  was  dropped,  not  on  account  of  its  danger,  but 
because  of  the  great  eclat  with  which  the  perineal  operations  were  received. 
So  completely  had  this  operation  been. disused  that  up  to  1851  only  260  cases 
could  be  collected,  and  between  1851  and  1879,  only  a  few  more  were  reported. 

Since  1879,  however,  it  has  been  rapidly  gaining  the  confidence  of  the  pro- 
fession, until  Dr.  Dennis  thinks  that  Dr.  Koberts'  prophetic  words  of  a  few 
years  since,  have  almost  been  realized,  viz.,  that  within  ten  years  the  supra- 
pubic operation  will  be  the  operation  adopted  for  all  cases  of  stone  that  are 
not  treated  by  Bigelow's  operation.  Dr.  Dennis  further  remarks  that  the 
time  is  not  far  distant  when  there  will  be  but  practically  two  operations  for 
stone  in  the  bladder,  the  suprapubic  lithotomy  and  litholapaxy.  "  It  is  simple 
in  its  technique,  safe  in  its  execution,  radical  in  its  results,  free  from  injury 
to  the  reproductive  organs,  curative  in  its  application,  and,  finally,  brilliant  in 
its  statistics." 

The  only  points  as  to  technique  we  can  refer  to,  are  that  no  perineal  drainage 
is  needed;  the  catheter  must  not  be  retained  for  more  than  forty-eight  hours 
lest  traumatic  urethritis  result ;  the  bladder  wound  in  stone  cases  should  be 
left  open,  while  in  rupture  it  may,  and  should  be  sewn — since  here  the  bladder- 
walls  are  healthy.  That  this  advice  is  good  is  proved  by  the  fact  that  re- 
opening of  the  wounds  occurs  in  two-thirds  of  those  sutured  after  stone 
operations. 

The  special  indications  for  exploration  of  the  bladder  by  the  suprapubic 
operation  are  found : 

1.  In  cases  of  lithotomy  for  large,  hard  calculi ;  also  in  lithotomy  occurring 
in  a  patient  suffering  from  paraplegia,  a  contracted  pelvis,  perineal  tumors, 
encysted  calculi,  ankylosis  of  the  hip,  hemorrhoids,  or  great  obesity. 

2.  For  the  removal  of  certain  foreign  bodies  as  hairpins,  bodkins,  needles, 
etc.,  for  the  treatment  of  chronic  cystitis,  and  for  the  operation  for  calculi  in 
the  female. 

3.  In  lithotomy  occurring  in  a  patient  with  greatly  enlarged  prostate,  or 
with  fibroma  of  the  prostate,  or  in  calculi  found  in  diverticula  behind  the 
prostate. 


564 


PROGKESS  OF   MEDICAL  SCIENCE. 


4.  For  the  excision  of  tumors  of  the  bladder. 

5.  For  rapture  of  the  bladder. 

The  advantages  are  stated  to  be  the  safe  removal  of  large,  hard  stones,  in- 
operable by  any  other  method ;  the  absence  of  risk  of  perineal  hemorrhage, 
urinary  infiltration,  perineal  fistula,  laceration  of  rectum  and  neck  of  bladder, 
the  prevention  of  traumatic  stricture  and  cystic  hemorrhage,  and  the  avoid- 
ance of  any  interference  with  the  genital  apparatus. 

In  young  women  no  risk  of  vesico-vaginal  fistula  exists,  nor  in  the  old, 
permanent  urinary  incontinence.  It  is  the  safest  operation  whatever  form  of 
renal  disease  exists,  and  the  only  means  of  saving  life  in  rupture  of  the 
bladder.  The  chances  of  recurrence  are  less  than  after  lithotrity.  Supra- 
pubic lithotomy  is  also  free  from  danger  during  its  performance.  Dr.  Dennis 
has  collected  124  suprapubic  lithotomies  performed  since  1879,  of  which 
number  eighteen  died.  Seven  of  these  deaths  we  agree  with  the  author 
should  be  subtracted,  leaving  a  mortality  of  only  about  nine  per  cent.  The 
causes  of  death  are  chiefly  secondary — i.  e.,  due  to  septic  infection,  not  to  the 
operation  itself,  and  this  mortality  can  probably  be  reduced  by  "  more  rigid 
antisepsis  for  the  bladder."  The  author  also  points  out  that  heretofore  this 
operation  has  been  reserved  for  stones  of  a  large  size,  and  is  in  consequence 
performed  in  patients  much  run  down,  so  that  when  resorted  to  earlier  and 
for  smaller  stones  the  mortality  will  diminish. 

Treatment  of  Anal  Fissure  and  Hemorrhoids  by  Gradual 
Dilatation. 

Dr.  H.  O.  Walker,  in  the  New  York  Medical  Journal  of  July  30,  1887, 
reports  that  he  has  treated  over  fifty  cases  of  this  nature  with  unvarying 
success  by  either  the  gradual  dilatation  by  the  finger  or  a  bivalve  rectal 
speculum.  The  first  dilatations  are  slight,  but  repeated  every  three  days 
until  the  instrument  can  be  expanded  to  its  utmost  capacity.  Topical  treat- 
ment with  tannin  and  glycerine,  or  iodoform  and  balsam  of  Peru,  is  men- 
tioned as  having  been  resorted  to  in  some  of  the  cases,  but  no  stress  is  laid 
upon  it.  If  the  author  is  correct  in  his  observations,  it  is  strange  that  iden- 
tical results  have  not  followed  the  somewhat  similar  methods  commonly  in 
vogue.  We  believe  the  topical  treatment  deserves  vastly  more  credit  than 
Dr.  Walker  accords  it. 

Horny  Growth  of  the  Penis. 

Dr.  J.  H.  Brinton,  in  The  Medical  News  of  August  6,  1887,  records  the 
history  of  a  growth  of  this  nature.  The  horn  was  one  and  seven-eighths  of 
an  inch  long,  by  one  and  three-eighths  in  circumference  at  its  base,  and  was 
curved  forward,  slightly  tapering,  and  sprang  from  the  base  of  the  glans  at 
the  coronal  border ;  it  was  firmly  attached  both  to  the  glans  and  to  the  pre- 
puce. On  the  dorsum,  half  an  inch  in  front  of  the  corona,  a  plate  of  horny 
tissue,  varying  in  width  from  three-quarters  of  an  inch  to  an  inch,  encircled 
the  end  of  the  glans,  covering  and  destroying  the  frenum  and  its  attachments, 
surrounding  the  meatus,  and  narrowing  it  to  a  pin's  point.  Through  this 
narrowed  opening,  impervious  to  any  instrument,  the  urine  escaped  slowly, 
drop  by  drop.    Owing  to  the  extent  of  disease,  and  the  involvement  of  the 


SURGERY. 


565 


urethra,  the  glans  was  removed  just  beyond  the  corona.  Microscopically,  the 
growth  consisted  in  all  parts  of  shrivelled,  closely  packed  squamous  epithelial 
cells,  "even  more  tightly  united  than  in  the  structure  of  the  living  nail," 
except  at  the  more  interior  portions,  and  in  the  lamellar  plates  covering  the 
glans.  Only  fourteen  similar  cases  have  been  put  on  record,  but  one  or  more 
are  vaguely  mentioned.  Although  occasionally  coincident  with,  or  followed 
by  an  epitheliomatous  condition,  they  have  been,  in  almost  all  instances,  pre- 
ceded by  a  wart,  as  in  the  present  case.  Free  removal  is  advocated,  the 
incisions  being  carried  well  beyond  the  diseased  borders. 

Appended  are  references  to  all  recorded  cases,  so  that  this  paper  at  a  glance 
puts  the  reader  in  possession  of  all  the  facts  with  regard  to  this  rare  affection. 

The  Correction  of  "  Pug-nose  "  by  a  Simple  Operation. 

Dr.  John  O.  Roe,  in  the  Medical  Record  of  June  4,  1887,  contends  that 
this  form  of  nose  is  a  sign  of  degeneracy ;  that  it  is  owing  to  the  overgrowth 
of  the  soft  parts,  the  result  of  interference  with  the  return  circulation  from 
obstruction  of  the  nasal  passages  in  childhood. 

After  applying  cocaine,  the  parts  are  illuminated,  the  end  of  the  nose  is 
turned  upward  and  backward,  the  mucous  membrane  is  dissected  from  those 
parts  to  which  it  is  not  too  adherent,  and  the  superfluous  tissue  is  removed 
so  as  to  allow  the  organ  to  conform  to  the  shape  we  desire.  Neither  too  much 
tissue  must  be  removed  nor  the  skin  cut  through.  In  some  cases  no  after- 
treatment  is  required,  but  replacement  of  the  dissected-up  mucous  mem- 
brane. In  others  a  saddle-like  splint  should  be  moulded  to  the  dorsum  of  the 
nose.  Where  the  deformity  is  due  to  bulging  out  of  the  alae  from  malforma- 
tion of  the  cartilages,  these  must  be  cut  through  at  various  points  with  a 
tenotome  so  as  to  destroy  their  elasticity,  after  w7hich  a  hard  rubber  or  silver 
tube  must  be  inserted  into  each  nostril,  and  the  "saddle"  before  mentioned 
moulded  to  the  outside  of  the  nose.  Illustrations  of  successful  cases  are 
given. 

Amputation  of  the  Breast  under  Cocaine  Anesthesia. 

Dr.  Daniel  Lewis,  in  the  Medical  Record  of  June  4,  1887,  reports  a 
successful  operation  on  a  patient  aged  seventy-eight  years.  Dr.  Corning  in- 
duced anaesthesia  by  his  method  of  application  of  a  rubber-coated  ovoid 
iron  ring  around  the  gland,  and  injections  into  the  layers  of  the  skin  of  a  two 
per  cent,  solution  of  cocaine  at  intervals  of  about  one-half  inch,  after  tracing 
the  line  of  the  proposed  incision  with  iodine.  Several  larger  injections  were 
made  beneath  the  tumor.  No  pain  was  felt  except  that  from  the  first  hypo- 
dermatic needle  puncture,  and  the  passing  of  the  last  sutures  in  a  small  section 
of  the  lower  flap.  Twenty-five  minutes  were  consumed  by  the  operation  and 
less  than  three  drachms  of  the  solution  was  used ;  healing  was  complete  in 
seven  days. 

Ligature  of  the  Internal  Jugular  Vein  for  a  Knife-cut. 

Dr.  F.  Tipton,  in  the  New  York  Medico/  Journal  of  July  2,  1887,  reports  a 
case  in  which  the  patient  ran  some  distance,  bleeding  profusely  ;  the  hemor- 
rhage was  temporarily  arrested  by  digital  pressure,  until  a  distal  ligature  was 


566 


PROGEESS   OF   MEDICAL  SCIENCE. 


passed  and  tied.  All  bleeding  was  arrested  until,  in  the  effort  to  avoid  syn- 
cope, the  patient's  head  was  lowered,  when  fresh  hemorrhage  took  place  from 
the  untied  proximal  portion  of  the  vessel,  which  had  been  only  cut  half  way 
through,  not  entirely  severed.  Elevation  of  the  head  at  once  and  perma- 
nently arrested  the  recurrent  bleeding.  Eecovery  ensued,  but  the  ligature 
remained  attached  for  several  months. 

We  are  surprised  that  a  proximal  ligature  was  not  applied  as  well  as  the 
distal,  a  rule  which  is  almost  as  imperative  for  a  large  wounded  vein  as  for  a 
wounded  artery. 

Base-ball  Pitcher's  Arm. 

Dr.  A.  H.  P.  Lettf  in  The  Medical  News  of  July  16,  1887,  considers  this 
subject  most  exhaustively.  Practically  any  of  the  muscles  of  the  upper  ex- 
tremity and  of  the  right  side  of  the  trunk  may  be  affected,  but  the  trouble 
usually  commences  in  the  brachialis  anticus.  In  its  severer  forms,  muscles, 
ligaments,  cartilages,  and  even  the  osseous  tissues  are,  in  Dr.  Leuf 's  opinion, 
involved. 

The  author's  views  as  to  prophylaxis  seem  sound,  but  as  to  treatment 
amount  to  little  more  than  regular  daily  exercise,  "  to  bring  to  a  climax  and 
final  completion  those  congestive  and  inflammatory  processes  in  the  muscles, 
ligaments,  cartilages,  and  bones  that  lead  to  hypertrophy  and  necessary  in- 
crease in  strength."  These  are  certainly  novel  pathological  views,  although 
the  practice  may  be  good.  In  the  more  severe  forms  "  mild  galvanism," 
making  use  of  large  flat  electrodes  applied  over  the  most  sensitive  points  in 
front  of  and  behind  the  affected  joints,  is  recommended,  the  latter  part  of  the 
day  being  the  preferable  time. 


OP  HTHALMOLO  GY. 


UNDER  THE  CHARGE  OF 

L.  WEBSTER  FOX,  M.D., 

OPHTHALMIC  SURGEON  TO  THE  GERMANTOWN  HOSPITAL,  PHILADELPHIA. 


Etiology  of  OculAr  Paralyses. 

In  the  Recueil  d' Ophthalmologic  for  March,  1887,  Prof.  Fotjrnier  sets  out 
the  distinctions  between  the  symptoms  of  ocular  paralyses,  caused  by  ataxia, 
and  those  from  lesions  of  the  ocular  nerves.  If  symptomatic  of  tabetic  disor- 
ders, he  finds  the  following  distinctive  points  : 

1.  The  paralyses  are  almost  always  single  or  in  groups,  and  partial;  the 
pupil  is  often  implicated  in  a  peculiar  manner. 

2.  There  is  either  the  Argyll-Robertson  pupil  or  myosis. 

3.  The  paralyses  are  often  of  short  duration,  sometimes  for  an  instant  only. 

4.  They  are  especially  liable  to  recur,  and  often  cease  spontaneously  and 
quickly. 


OPHTHALMOLOGY. 


567 


If  of  the  following  characters,  a  lesion  of  the  nervous  system  is  probable: 

1.  If  the  paralysis  be  complete. 

2.  If  persistent. 

3.  If  relieved  only  by  specific  treatment,  long  continued. 

Of  62  cases  of  tabetic  paralysis,  the  author  found  but  a  single  one  with  total 
paralysis  of  the  ocular  muscles.  Of  the  62  cases  the  pupil  was  affected  in  37, 
of  which  28  had  no  other  muscles  implicated.  Of  the  9  remaining  cases  out 
of  the  37,  in  which  other  muscles  were  affected,  there  were  3  cases  of  paralysis 
of  the  levator  and  of  the  internal  rectus,  2  of  the  levator,  2  of  the  internal 
rectus,  1  of  the  inferior  rectus,  and  1  of  the  levator  and  inferior  rectus.  Of 
the  62  cases  there  were  15  myoses,  11  of  which  were  without  implication  of 
other  muscles.  The  author  emphasizes  the  existence  of  a  passing  strabismus 
or  of  temporary  diplopia,  as  thus  often  indicative  of  locomotor  ataxia. 

The  Bacillus  of  Catarrhal  Conjunctivitis. 

Dr.  J.  E.  Weeks  (Arch.  f.  Augenheilkunde,  xvii.  3,  p.  318)  describes  a 
bacillus  obtained  from  an  acute  case  of  catarrhal  conjunctivitis,  that  he  thinks 
the  source  of  the  infection.  Two  kinds  of  bacilli  were  found  in  the  cultures, 
but  the  rod-like  variety  was  proved  by  cultures  to  have  no  pathogenic  quality. 
The  one  producing  the  inflammation  was  shorter  than  the  tubercle  bacillus, 
but  of  about  the  same  thickness.  The  period  of  incubation  after  inoculatiou 
wras  about  forty-eight  hours ;  inoculation  always  produced  the  characteristic 
conjunctival  symptoms,  and  the  bacillus  in  every  case,  when  there  was 
yellowish  secretion,  was  always  present. 

Tuberculosis  of  the  Conjunctiva. 

In  Grafe's  Archiv,  Band  xxxii.  Abth.  iii.,  Dr.  Stolting  reports  three  cases 
of  this  serious  affection,  and  bespeaks  a  more  hopeful  prognosis  than  has 
heretofore  been  considered  possible,  and,  especially,  if  the  treatment  be  com- 
menced at  an  early  date.  The  diagnosis  of  the  disease  was  rendered  certain, 
in  one  case  by  the  production  of  the  characteristic  bacillus  under  the  micro- 
scope, in  the  second  by  inoculation  and  proof  of  the  existence  of  the  bacilli 
in  the  animal,  and  in  the  third  case  by  both  methods.  The  tuberculous 
ulcers  were  situated  respectively  upon  the  upper  lid,  the  cheek,  and  the 
lower  lid.  The  single  and  effective  therapeutic  measure  advocated  is  the 
complete  destruction  of  the  tuberculous  centre  and  deposit  by  the  thermo- 
cautery. In  some  cases  this  may  have  to  be  repeated,  or  more  thoroughly 
carried  out  at  successful  periods,  but  in  each  of  the  three  cases  cited,  com- 
plete success  was  finally  attained  by  this  means.  The  author  cautions  against 
unnecessary  destruction  of  healthy  adjacent  tissue,  such  as  would  cause  cica- 
tricial contractions,  disfigurement,  etc. 

Injuries  of  the  Eyes  by  Dynamite. 

Professor  A.  von  Hippel  (Graf e' 8  Archiv,  Band  xxxii.  Abth.  iii.)  de- 
scribes the  ocular  injuries  from  explosions  of  dynamite  in  twenty  oases 
that  have  come  under  his  care.  The  most  characteristic  changes  are  in  the 
cornea,  and  in  all  instances  consist  in  a  great  number  of  grayish-white,  punc- 


568  PKOG-RESS  OF   MEDICAL  SCIENCE. 

tate  opacities,  the  result  of  the  penetration  of  particles  of  sand,  stone,  etc., 
into  the  more  superficial  or  deep  corneal  strata.  The  corneal  epithelium  was 
in  all  cases  burnt  or  severely  injured.  The  most  serious  and  frequent  com- 
plication of  the  many  that  may  occur  is,  besides  the  loss  of  superficial  sub- 
stance, the  perforating  wounds  of  the  cornea.  The  sclerotic  was  seldom 
perforated.  In  only  one  instance  was  any  considerable  fragment  of  stone, 
etc.,  found  within  the  globe.  The  more  severe  injuries  ended  in  loss  of  the 
eye  by  panophthalmitis  or  irido- choroiditis.  Of  the  twenty  cases,  eight 
became  blind  in  both  eyes,  seven  in  one  eye,  the  vision  of  the  remaining  eye 
being  very  bad. 

Ocular  Injury  by  Lightning. 

Dr.  M.  Knies  {Graf e' 's  Archiv,  Band  xxxii.  Abth.  iii.)  describes  a  case  of 
this  rare  occurrence.  A  ten  year  old  boy  was  struck  with  what  might  be 
called  a  spent  bolt,  while  standing  by  an  open  window.  He  at  once  turned 
around  several  times  slowly  and  in  a  peculiar  manner,  fell  backward  to  the 
floor,  and  was  unconscious  for  two  hours.  Upon  the  return  of  consciousness, 
both  eyes,  especially  the  right,  were  found  much  swollen  and  flowing  with 
tears.  The  child  was  weak,  dazed,  slept  a  great  deal,  but  had  no  headache. 
Four  days  later  the  oculist  found  fresh  irregular  wounds  of  the  forehead  and 
temple,  and  these  extended  down  the  right  sterno-mastoid  and  the  side  of  the 
body  to  the  foot.  The  skin  of  the  forehead  was  in  folds  from  the  constant 
contraction  of  the  frontalis  muscle.  The  eyebrows  and  lashes  were  burned 
upon  both  sides,  and  there  was  incomplete  ptosis  with  ciliary  injection  and 
diffuse  corneal  opacity.  Upon  the  right  side  there  was  a  large  posterior  stellar 
polar  cataract  and  further  lenticular  opacity  from  the  equator  to  the  anterior 
cortex.  There  was  complete  amaurosis,  but  a  normal-sized  and  acting  pupil. 
In  the  left  eye  there  was  beginning  cataract  and  a  normal  fundus,  with  vision 
one-half,  not  improved  by  lenses.  The  ocular  motility  was  not  interfered 
with  upon  either  side.  The  right  cataractous  lens  was  partially  removed  at  a 
later  date,  but  the  patient  passed  from  observation,  and  the  final  results  are 
not  to  be  had.  Two  sets  of  consequences  are,  therefore,  to  be  distinguished  : 
First,  the  direct,  consisting  in  the  burning  of  the  lashes,  the  flesh  wounds 
made  by  the  electric  stream,  the  injuries  to  the  nerves  or  muscular  tissues  by 
the  same ;  second,  the  indirect,  the  iritis,  the  irido-cyclitis,  the  cataracts,  etc. 

Eelations  of  Corneal  Curvature  to  Cranial  Circumference. 

Bourgeois  and  Tscherning  {Annates  d: '  Oculistique,  xcvi.  p.  203),  from  the 
measurements  of  203  soldiers,  found  that  the  radius  of  corneal  curvature 
varied  in  proportion  to  the  circumference  of  the  head.  Whilst  the  first  rose 
from  7.78  mm.  to  7.92  mm.,  the  cranial  measurements  were  from  54  to  60  cm. 

Irido-cyclitis  Tuberculosa. 

Tuberculosis  of  the  uveal  tract  is  a  rare  disease  occurring  not  more  fre- 
quently than  once  in  about  5000  cases  of  ocular  disease.  Therefore,  the 
case  described  in  detail  by  Dr.  August  Wagenmann  (Graf e' s  ArcMv, 
Band  xxxii.  Abth.  iv.)  posesses  a  peculiar  interest.    The  patient  was  a  man 


OPHTHALMOLOGY. 


569 


of  forty-four  years  of  age  (February  3,  1886),  had  no  tuberculous  family 
history,  and  syphilis  was  excluded.  The  anterior  chamber  was  partially  filled 
with  pus,  there  was  prolapse  of  the  upper  portion  of  the  iris,  the  tarsal  con- 
junctivae were  extremely  congested.    There  was  no  fundus  reflex,  the  ciliary 

20  20 

region  was  very  sensitive  to  pressure,  the  visual  acuity,  _^^to—  .     The  eye 

was  enucleated  on  February  5,  and  the  suspected  tuberculosis  was  proved  by 
finding  the  characteristic  bacilli,  and  by  the  inoculation  of  animals  with  the 
pus.  Dr.  Wagenmann  finds  from  a  review  of  the  literature  of  the  subject, 
that  the  disease  is  usually  chronic  and  monocular,  generally  limited  to  the 
age  of  childhood,  and  may  be  painful  or  not  according  to  circumstances. 
Early  enucleation  is  always  advisable,  since,  the  diagnosis  being  certain,  there 
can  be  no  hope  of  saving  the  eye,  and  by  this  measure  as  well  as  by  general 
treatment,  a  great  improvement  in  health  is  at  once  observed. 

The  Pupillary  Immobility  of  Progressive  Paralysis. 

Mcelli's  study  of  this  subject  (Archiv  f.  Psych.,  xviii.,  1887)  is  based  upon 
500  cases.  In  about  half  of  the  cases  the  light-reflex  was  destroyed  or  much 
below  the  normal.  In  only  twenty-eight  per  cent,  was  there  good  reaction. 
Mydriasis  is  much  more  infrequent  than  myosis.  There  were  twenty  cases 
of  pupillary  immobility  in  non-paralytic  patients.  In  the  majority  of  these 
cases  syphilis  or  alcohol  was  the  probable  cause.  Binocular  immobility  ex- 
isted in  twelve  cases  without  cerebral  or  paralytic  disease,  and  in  half  of  these 
cases  syphilis  was  the  undoubted  source. 

The  Belation  between  Choroidal  Crescent  and  Astigmatism. 

Georges  Martin  (Annates  d'  Oculistique,  Mars,  Avril,  1887)  gives  the  results 
of  his  studies  of  the  relation  of  the  choroidal  crescent  about  the  papilla  to 
the  axis  of  astigmatism,  and  finds  in  the  great  majority  of  cases,  perhaps  in 
all,  that  the  crescent  is  situated  at  the  extremity  of  a  partial  contraction  of 
the  ciliary  muscle,  and  that  this  contraction  is  the  cause  of  its  appearance 
and  development.  All  eyes  with  a  crescent,  he  finds,  are  astigmatic,  and  the 
direction  of  the  lesion  is  in  a  plane  parallel  to  one  of  the  principal  meridians, 
generally,  in  the  one  of  least  refraction.  In  358  cases  of  regular  or  vertical 
astigmatism,  336  crescents  were  external  and  22  inferior.  In  24  cases  of 
horizontal  astigmatism,  the  crescent  was  vertical  in  every  case.  Of  22  cases 
of  oblique  astigmatism,  the  crescent  was  vertical  15  times,  and  7  times  was 
parallel  to  the  axis  of  corneal  astigmatism.  In  dynamic  or  lenticular  astig- 
matism of  the  9  cases  reported,  the  crescent  and  spasmodic  astigmatism  had 
the  same  direction.  In  413  cases,  therefore,  of  all  kinds  examined,  the  rela- 
tion was  proved  to  exist  in  384  instances; or  in  about  93  percent.  In  77  cases 
that  are  tabulated,  13  were  emmetropes,  7  hyperopes,  and  55  myopes,  2  cases 
not  being  determined. 

Cases  of  Primary  Glaucoma  in  the  Young. 

Two  interesting  cases  of  glaucoma  in  young  people  are  reported  by  Dr.  O. 
Lange  in  Grafe's  Archiv,  Band  xxxiii.  Abth.  i.  The  first  was  in  a  man 
of  twenty,  and  had  continued  with  the  usual  symptoms  of  clouded  vision. 


570 


PROGKESS   OF   MEDICAL  SCIENCE. 


rings  about  lights,  frontal  headaches,  etc.,  for  over  a  year,  with  many  sub- 
acute attacks.  Latterly  the  abnormal  increase  of  intraocular  pressure  had 
the  peculiarity  of  an  exact  rhythmical  occurrence.  In  the  morning  the  pres- 
sure was  high,  decreasing  toward  noon,  and  disappearing  entirely  during  the 
latter  part  of  the  day.  At  first,  eserine  controlled  the  glaucomatous  symp- 
toms, but  it  finally  became  powerless  to  affect  the  periodical  rise  and  fall  of 
the  pressure.  A  sclerotomy,  according  to  de  Wecker's  method,  gave  perma- 
nent relief  for  several  years,  when  the  attacks  again  came  on,  and,  eserine 
once  more  proving  of  no  avail,  an  iridectomy  was  made  with  the  desired 
result  of  relief  up  to  date.  In  the  second  case,  a  girl  of  twenty-two,  the 
primary  attack  was  connected  with  an  amenorrhcea  of  seven  months'  standing. 
A  de  Wecker  sclerotomy  gave  complete  relief  from  what  had  been  severe  and 
frequent  attacks  of  the  usual  glaucomatous  symptoms.  The  author  also 
adduces  an  instructive  case  of  recurring  glaucoma  in  a  clarionet  player,  who 
was  always  seized  with  an  attack  after  playing  upon  his  instrument.  Eserine, 
previous  to  an  evening's  engagement,  always  aborted  the  attacks.  From 
these  instances  Lange  argues  that  the  glacomatous  tension  may  be  superin- 
duced by  circulatory  disturbances,  though  he  is  so  far  from  exclusively 
accepting  this,  or  any  other  theory,  that  he  sharply,  and  with  much  effective- 
ness, criticises  those  who  thus  accept  any  exclusive  dogma  of  the  etiology  of 
the  affection.  Eserine,  which  enlarges  the  vessels,  is,  for  this  reason,  deemed 
to  have  its  good  influence  in  reducing  the  tension,  but  the  author  seems  to 
forget  that  amyl  nitrite  has  no  such  effect  upon  the  intraocular  tension. 
Mauthner's  astounding  theory  that  the  increased  tension  does  not  necessarily 
belong  to  the  glaucomatous  symptoms,  is  as  sharply  criticised  as  the  reverence 
due  to  great  names  will  allow.  As  to  the  relative  frequency  of  glaucoma  in 
hyperopia  and  myopia,  the  author  would  modify  the  common  belief  that  it  is 
indiscriminately  and  excessively  higher  in  hyperopia.  Of  his  163  cases  of 
primary  glaucoma,  he  finds  that  of  69  cases  of  glaucoma  simplex,  30  were  in 
myopic  eyes,  and  38  in  hyperopic.  In  glaucoma  cum  injectione,  the  proportions 
were  about  as  commonly  given :  10  in  myopes  and  81  in  hyperopes.  In  the 
Archives  of  Ophthalmology  for  June,  Dr.  R.  L.  Randolph  reports  a  case  of 
glaucoma  in  both  eyes  in  a  child  of  eleven  years  that  had  existed  for  over  a 

year.    No  clew  was  obtained  as  to  a  family  history.    Vision  was  —  in  the 

36 

6 

right  eye,  —  in  the  left,  both  eyes  were  under  abnormal  intraocular  pressure, 
60 

the  left  being  of  a  stony  hardness  to  the  touch.  The  papillae  were  cupped, 
and  there  was  venous  pulsation.  The  disease  was  not  complicated  with  any 
other  that  could  be  learned.    Operation  was  declined. 

The  Pathological  Anatomy  of  Glaucoma. 

Bib-jSTBACHEB,  and  Czermak  {Graf J  s  Archiv,  xxxii.  2  and  4)  present  an 
excellent  account  of  the  minute  anatomy  of  seven  glaucomatous  eyes.  The 
general  results  are  in  harmony  with  Schulten's  experiments,  viz.,  that  any 
causes  that  increase  the  difficulty  of  the  venous  outflow,  or  that  increase  the 
arterial  supply,  tend  to  raise  the  intraocular  tension.  It  is  shown  that  the 
eyes  under  study  give  evidence  of  circumstances  operating  toward  increased 


OPHTHALMOLOGY. 


571 


pressure,  in  that  there  is  lessened  lumen  of  the  veins,  caused  by  inflammatory 
changes  and  thickening  of  their  walls,  which  changes  also  had  the  effect  of 
cutting  off  the  ready  escape  of  lymph  and  other  fluids.  The  primary  source 
of  the  mischief  is  thought  to  consist  in  injuries  of  the  uveal  tract  consequent 
upon  inflammation,  which  prevent  the  escape  of  lymph  and  venous  blood. 

The  Influence  op  Mydriatics  and  Myotics  upon 
Intraocular  Pressure. 

In  Grafe's  Archiv,  Band  xxxiii.  Abth.  i.,  Dr.  Friederich  Stocker  pub- 
lishes the  results  of  his  numerous  experiments  with  the  principal  mydriatics 
and  myotics  upon  the  intraocular  pressure  of  cats,  under  normal  or  physio- 
logical conditions.  Morphine  and  chloroform  were  found  ill-adapted  as  nar- 
cotics, and  curare  alone  was  resorted  to.  The  tension  was  measured  with  a 
manometer,  especially  constructed  for  the  purpose.  The  reader  may  be 
astonished  to  learn  that  the  invariable  result  of  the  extended  experiments 
was,  that,  under  the  influence  of  atropine,  there  was  a  slow  diminution  of  the 
intraocular  pressure.  With  cocaine  there  was  also  a  lessening  of  the  tension 
in  every  instance,1  preceded,  however,  in  the  majority  of  cases',  by  a  slight 
temporary  increase  of  the  tension.  With  eserine  there  resulted  an  increase 
of  tension  without  any  stage  of  diminished  tension,  but  the  final  effect  of 
eserine  was  to  reduce  the  pressure  to  a  greater  degree  than  it  had  been  raised. 
Pilocarpine  slowly  reduced  the  tension  after  a  preliminary  stage  of  strongly 
varying  pressure,  during  which  there  was  an  average  elevation  of  pressure  in 
both  eyes.  In  all  the  experiments  it  was  proved  that  the  pupillary  play 
stands  in  no  necessary  and  essential  relation  either  to  the  increase  or  decrease 
of  tension.  This  result  is  in  direct  contradiction  to  the  conclusions  of  Holztke 
and  Graser,  who  found  (No.  13,  Verhandl.  d.  physiol.  Geselhch,  zu  Berlin)  that 
the  pressure  was  raised  with  the  widening,  and  fell  with  the  narrowing,  of  the 
pupil.  Regarding  the  radius  of  the  corneal  curve,  the  experiments  show  that 
the  mydriatics  atropine  and  cocaine  have  no  influence  upon  it,  in  so  far  as 
may  be  learned  by  the  ophthalmometer.  The  myotics  eserine,  and  pilocar- 
pine have  the  effect  of  shortening  the  radius  during  the  myosis  by  one-tenth 
to  two-tenths  of  a  millimetre. 

Subconjunctival  Scleral  Fistula  in  Glaucoma. 

M.  Motais  communicated  to  the  French  Ophthalmological  Society  (Seance 
of  May  4— v.  Recuil  d'ophth.,  June,  1887)  his  method  of  operation  in  cases  of 
hopeless  glaucoma.  When  iridectomies  are  impossible,  or  have  been  proved 
of  no  avail  to  lessen  the  abnormal  tension,  and  when  other  devices  have  failed, 
and  an  enucleation  seems  inevitable,  M.  Motais  recommends  the  establishing 
of  a  fistula.  He  rotates  the  globe  downward  and  inward,  and  plunges  a  knife 
into  the  vitreous  at  a  point  between  the  tendons  of  the  superior  and  external 
rectus.  The  pressure  of  the  eye  prevents  the  healing  of  the  sclerotic  wound, 
but  the  conjunctiva  soon  heals,  and  a  subconjunetival  fistula  is  formed,  so 

1  Elizabeth  Sargent,  M.D.,  in  Archives  of  Ophthalmology  for  Juno,  reports  a  case  of  diminution  of 
intraocular  pressure  in  a  woman,  and  relief  from  pain  and  other  glaucomatous  symptoms  for  six  or 
seven  months,  by  the  instillation  of  cocaine. 


572 


PEOGEESS  OF   MEDICAL  SCIENCE. 


that  the  intraocular  fluids  are  in  communication  with  the  subconjunctival 
pocket.  In  the  fifteen  cases  so  treated  in  the  past  three  years,  there  was  a 
temporary  relief  in  but  two,  owing  to  the  failure  of  the  fistula  to  become  per- 
manently established.  In  the  thirteen  successful  cases  the  tension  has  re- 
mained normal,  and  the  pain  and  other  glaucomatous  symptoms  have  not 
returned. 

The  Spontaneous  Absorption  of  Senile  Cataract. 

Dr.  Paul  Meyer,  in  Grafts  Arckiv,  Band  xxxiii.  Abth.  i.,  reviews  the 
literature  of  the  reported  cases  of  spontaneous  absorption  of  senile  cataract. 
He  finds  that  many  are  open  to  doubt  and  discussion,  but  that  others,  and 
especially  the  more  recent  cases,  are  so  carefully  observed,  and  with  such 
intelligence,  that  denial  of  the  fact  is  no  longer  possible.  There  is,  of  course, 
no  question  that  juvenile  cataract  is  frequently  so  absorbed,  but  as  to  senile 
absorption,  conservative  thought  has  heretofore  been  inclined  to  doubt  either 
the  accuracy  of  the  previous  diagnosis,  or  the  trustworthiness  of  the  report  of 
reinstated  vision.  In  the  June  number  of  the  American  Journal  of  Ophthal- 
mology, Dr.  Charles  J.  Kipp  supplements  the  meagre  literature  with  another 
case  of  spontaneous  absorption  of  senile  cataract  without  injury  to  the  cap- 
sule of  the  lens,  and  with  a  restoration  of  excellent  vision.  The  case  is  well 
reported,  and  there  seems  to  be  no  doubt  of  the  accuracy  of  the  statement. 

The  Relation  of  Accommodation-strain  to  Glaucoma  and 
Cataract. 

To  the  ophthalmic  surgeon  the  three  ocular  affections  of  exceptional  im- 
portance are  certainly  those  mentioned  in  the  above  title,  and  in  uniting 
the  three  in  a  nexus  of  cause  and  effect  Dr.  W.  ScHOEN,((rro/e's  Archiv,  Band 
xxxiii.  Abth.  i.)  decidedly  justifies  his  happy  motto :  simplex  sigillum  veri. 
There  can  be  little  doubt  that  we  are  only  beginning  to  realize  the  wide- 
spread and  variously  injurious  effects  of  eye-strain  upon  the  organism  gener- 
ally, and  upon  the  eye  in  particular.  That  the  accommodation-strain  of 
ametropic  eyes  may  produce  glaucoma  and  cataract  is  the  thesis  that  Dr. 
Schoen  renders  far-more  than'plausible.  In  hyperopic,  astigmatic,  and  pres- 
byopic eyes  (the  ones  peculiarly  strained)  the  persistent  and  irritating  strain 
of  the  ciliary  muscle  upon  its  two  attachments  leads  to  the  accommodative 
excavation  on  the  one  side,  and  to  folding  of  the  lens  capsule  with  radial 
opacity  on  the  other.  Eighty  per  cent,  of  the  patients  subjected  to  accommo- 
dation-strain showed  the  expected  accommodative-excavation.  Of  95  cases  of 
equatorial  cataract,  92  showed  the  excavation,  and  there  were  in  these  95  cases, 
39  astigmatics,  39  hyperopes,  11  presbyopes,  and  4  whose  refraction  could  not 
be  determined — nearly  or  quite  100  per  cent,  showing  uncorrected  refractive 
error.  There  was  no  case  of  nuclear  opacity  without  equatorial  cataract,  and 
90  cases  of  the  latter  without  the  nuclear  sclerosis,  showing  that  the  equator 
is  the  starting  point  of  the  opacity.  Besides  refractive  errors,  leucoma  of  the 
cornea,  extremely  fine  work,  wearing  too  strong  convex  glasses,  etc.,  may 
produce  the  strain.  The  consequences  are,  accommodative  excavation,  cap- 
sular folds,  and  hypertrophy  of  capsular  epithelial  structure,  with  other  sub- 
sidiary injuries,  such  as  overcorrected  astigmatism  (by  the  lens),  halo,  venous 


OPHTHALMOLOGY. 


573 


pulsation,  blepharospasm,  inflammation,  etc.  The  final  results  are  glaucoma 
simplex,  cataract,  glaucoma  acutum. 

Visual  Disturbances  Kesulting  from  Cauterization  of  the 
Nasal  Passages. 

In  the  Archiv  fur  Augenheilkunde,  xvii-iii.,  E.  Berger  describes  a  case 
believed  by  him  to  be  unique,  where  the  application  of  the  galvano-cautery  to 
the  nasal  passages  produced  a  decided  amblyopia  ("everything  as  if  through  a 
thick  fog").  The  subsequent  spontaneous  recovery  was  gradual.  In  the  Cen- 
tralblatt fur  praktische  Augenheilkunde  for  May,  1887,  Dr.  Zien  presents  three 
similar  cases  of  ocular  troubles.  In  the  first  case  cauterization  of  the  hyper- 
trophied  mucous  membrane  of  the  middle  turbinated  bone  of  the  right  side 

20 

was  followed^by  indistinctness  of  sight  of  the  right  eye.  Sph.  4-  4.5  gave  V.  ~ 

20 

with  the  right  eye;  sph.  4-  4.00,  V.  —  of  the  left.    There  was  pulsation  of  the 

veins  of  the  right  papilla ;  none  in  the  left.  There  was  also  slight  limitation 
of  the  right  visual  field  as  compared  with  that  of  the  left.  In  the  second  case, 
•cauterization  of  a  small  tumor  in  the  inner  canthus  of  the  left  eye  was  fol- 
lowed by  impaired  vision  and  decided  hyperemia  of  the  papilla  of  the  left 
<eye.  In  the  third  case  cauterization  of  the  nasal  passage,  followed  by  some 
hemorrhage,  seemed  to  reduce  the  intraocular  tension,  and  to  produce  pro- 
nounced venous  pulsation  and  papillary  hyperemia. 


Epidemic  Hemeralopia. 

In  the  Archiv  fur  Augenheilkunde  of  June,  1887,  Dr.  Theodore  Kubli  re- 
counts a  curious  phenomenon  occurring  in  Russia  in  connection  with  the 
-church  fasts  before  Easter.  Meats  and  even  eggs  are  forbidden,  and,  as  the 
period  of  fasting  lasts  for  seven  weeks,  there  is  a  great  deal  of  resultant  ill 
nutrition  of  the  body.  With  other  organs,  the  eye  feels  the  effects  of  this 
regimen.  Out  of  19,588  cases  of  ocular  affections  in  one  hospital  in  St.  Peters- 
burg, from  1882  to  1887,  there  were  320  cases  of  hemeralopia,  nearly  every 
patient  being  of  the  orthodox  faith,  and  the  hemeralopia  appearing  during  the 
fasting  season.  During  the  other  fasts,  extending  over  much  shorter  periods 
of  time,  there  were  but  few  cases  presented.  As  concerns  the  ages,  the  older 
the  person  the  greater  the  immunity.  Of  200  cases  of  men  there  were  61  cases, 
each,  from  10  to  20  and  from  20  to  30  years  of  age ;  43  from  30  to  40 ;  18  from 
40  to  50;  12  from  50  to  60  ;  5  from  60  to  70.  Among  the  number  many  had 
had  the  hemeralopia  every  year  from  youth.  Pregnancy  predisposes,  but  it 
is  noteworthy  that  of  the  320  cases  241  were  men.  Other  ocular  symptoms 
than  the  hemeralopia  were,  of  course,  frequently  present,  as  epiphora,  bleph- 
aritis, conjunctivitis,  xerosis,  keratitis,  etc.,  but  there  were  no  considerable 
ophthalmoscopic  changes,  and  the  range  of  accommodation  was  not  affected. 
The  field  [?]  and  the  color  sense  were  also  normal.  Diminished  reaction  to 
light  was  the  distinguishing  symptom.  With  Forster's  photometer  15  cases 
had  less  than  one-half  the  normal  sensitiveness,  9  cases  less  than  one-tenth, 
11  less  than  one-twentieth,  8  less  than  one-fiftieth,  and  seven  less  than  one- 


574 


PKOG-RESS   OF   MEDICAL  SCIENCE. 


hundredth.  The  hemeralopia  at  once  disappears  with  the  resumption  of  a 
better  diet.  Other  therapeutic  measures  were  ineffectual.  The  popular  re- 
medy is  therefore  the  best,  and  this  is  cooked  liver,  an  article  of  food  not  held 
to  be  meat  by  the  rigorous  devotees  ! 

Miners'  Nystagmus. 

In  his  interesting  lecture  on  this  affection  (Brit.  Med.  Journ.,  July  16, 1887) 
C.  S.  Jeaffreson  brings  both  clinical  facts  and  general  logic  to  show  that 
the  theory  of  the  local  character  of  the  disease  advocated  by  Mr.  Simon  Snell 
and  others  is  no  longer  tenable.  Many  facts  go  to  show  that  the  disease  is  of 
central  origin,  and  that  the  general  system  may  largely  share  in  the  morbid 
process.  Choreic  movements  of  the  face  and  extremities,  frontal  headache, 
epigastric  fluttering,  spinal  pain,  general  distress,  and  even  a  kind  of  cardiac 
nystagmus  are  some  of  the  symptoms  noted,  and  also  go  far  to  disprove  the 
theory  of  Dr.  Dransart,  of  Belgium,  that  the  essential  feature  of  the  disease 
is  a  myopathy  of  the  elevator  muscles  of  the  globe.  The  lecturer's  theory  is 
that  the  miners'  position  produces  an  interference  of  vascular  supply  of  the 
head  generally,  but  chiefly  of  the  parts  supplied  by  the  basilar  arteries. 
Hence  the  ill-nutrition  of  the  visual  centres,  and  the  frequent  hemianopsia. 
There  is  probably  also  an  injurious  pressure  of  the  tentorium  cerebelli  upon 
the  pons,  caused  by  the  miners'  position,  and  the  cerebellar  function  being 
the  coordination  of  muscular  action,  it  also  may  be  interfered  with  by  the 
causes  mentioned. 

Beport  on  500  Enucleations  of  the  Eyeball. 

Dr.  d'Oench's  report  of  500  enucleations  by  Dr.  Knapp  (Archives  of  Op hth., 
June,  1887)  is  remarkable  for  the  quantity  of  clinical  material  shown.  As  re- 
gards the  causes :  234,  or  about  45  per  cent.,  were  enucleated  on  account  of 
injury,  48  of  which  were  because  of  a  foreign  body  in  the  interior.  "In  8  of 
them  an  attempt  at  removal  was  made."  Tumors  ranked  next  to  injuries ; 
glioma,  18  cases  (11  in  males,  6  in  females,  1  unknown);  sarcoma  led  to  30 
enucleations;  carcinoma  to  9;  enchondroma  to  1.  A  "slow  cyclitic  process" 
led  to  74  enucleations;  phthisical  eyeball  to  40;  painful  stump  to  8;  staphy- 
lomas to  41  (16  anterior,  15  total,  10  ciliary);  absolute  glaucoma  to  8;  ossifi- 
cation of  the  choroid  to  6,  etc.  In  answer  to  the  question  whether  it  is  safe 
to  remove  an  eye  in  which  panophthalmitis  has  developed,  the  statistics  given 
show  20  successful  cases  out  of  21  operated  upon.  30  cases  of  death  are  re- 
ported after  enucleation. 

The  Influence  of  Chronic  Alcoholism  upon  the  Eye. 

Dr.  W.  Uhthoff's  noteworthy  article  upon  this  subject  in  Grafe's  Archiv, 
Band  xxxii.  Abth.  iv.,  gathers  to  a  focus  the  clinical  and  anatomical  results 
of  the  study  of  1000  cases  of  chronic  alcoholism.  As  regards  the  pathological 
anatomy,  the  conclusions  are  based  upon  the  dissection  and  microscopical 
examination  of  seven  cases,  and  the  lesion  is  found  to  consist  of  a  retrobulbar 
optic  neuritis  with  secondary  atrophy  of  the  fibres.  There  is  a  wedge-shaped 
massing  of  the  nerve  fibres  about  the  macula  pointing  to  the  central  vessels. 


OPHTHALMOLOGY. 


575 


At  this  point  there  is  an  interstitial  neuritis  and  degeneration,  which  is  more 
severe  in  the  retrobulbar  portions  of  the  nerve  and  extending  to  the  cranial 
part  of  the  same.  There  is  a  pronounced  increase  of  the  intraneural  con- 
nective tissue,  though  healthy  nerve  fibres  are  always  found  running  through 
this  network,  and  in  the  majority  of  cases  the  greater  part  of  the  fibres  main- 
tain their  functional  activity.  From  this  fact  is  explained  the  common 
observation  that  even  with  positive  ophthamoscopic  lesions,  vision  usually 
remains  normal  or  but  slightly  impaired. 

The  cranial  portions  of  the  optic  nerve  and  its  branches  were  not  examined, 
but  the  degenerative  changes  became  less  marked  the  further  they  were 
followed  from  the  eye.  They  were  generally  of  a  crescentic  shape  in  the 
retrobulbar  portions  of  the  nerve.  No  formation  of  new  vessels  was  noted. 
The  degenerate  fibres  were  those  of  the  inferior  and  external  quadrant  of  the 
papilla,  those,  therefore,  supplying  the  upper  and  inner  quadrant  of  the  visual 
field,  and  were  wholly  made  up  of  the  direct  or  uncrossed  fibres.  The  macula 
fibres  were,  if  at  all,  only  slightly  implicated.  Paleness  of  the  temporal  half 
of  the  papilla  was  a  constant,  and  the  most  pronounced  ophthalmoscopic 
symptom  in  the  cases  that  were  subsequently  examined  post-mortem.  In  four 
out  of  the  seven  such  cases,  there  had  been  little  or  no  previous  visual  dis- 
turbance ;  in  the  others  vision  was  more  or  less  below  the  normal.  Simple 
gray  degeneration  of  the  optic  nerve  was  not  observed. 

Of  the  total  1000  cases  that  came  under  observation,  139  had  pronounced 
temporal  paleness  of  the  papilla,  and  of  these,  there  were  60  instances  of 
visual  impairment,  either  existing  at  the  time  or  that  had  been  previously 
noted.  Of  these  60,  five  only  had  had  visual  trouble  for  but  two  months  or 
less,  whilst  with  the  rest  it  had  existed  from  six  months  to  fifteen  years.  In 
26  patients  that  were  certain  of  a  previously  existing  visual  defect,  there  had 
taken  place  a  reinstatement  of  visual  acuity  so  that  they  could  read  Sn.  1., 
though  central  scotomata  for  green  and  red  were  often  found  present.  Indeed, 
as  is  well  known,  color-sense  was  much  more  affected  than  simple  light  reac- 
tion, green  and  red  sometimes  producing  no  peripheral  response.    In  only  2 

cases  was  the  amblyopia  excessive,       being  the  measure  in  1  case,  and  in 

the  other  an  absolute  central  scotoma  with  a  perimacular  zone  only  slightly 
sensitive  to  light.  There  was  no  case  of  absolute  blindness.  In  8  cases  the 
atrophic  portion  of  the  papilla  was  only  one-fourth,  or  less,  of  its  surface.  In 
every  instance  (of  the  60)  the  lesions  were  of  both  eyes.  In  the  remaining 
cases,  65  of  the  139,  there  was  no  complaint  of  amblyopia.  12  had  the 
whitened  papilla  in  but  one  eye ;  in  15  cases  it  was  only  slightly  pale.  In  10 
cases  it  was  characteristically  and  decidedly  whitened,  without  producing 
any  visual  disturbance  ;  in  8  cases  tests  were  impossible,  owing  to  the  patient's 
condition,  etc.  In  4  cases,  in  addition  to  the  temporal  change  of  color  of 
the  papilla,  there  was  also  paleness  of  the  inner  half,  though  less  in  degree, 
coexisting  twice  with,  twice  without,  defective  vision. 

In  the  1000  cases  there  were  9  of  amblyopia  without  any  ophthalmoscopic 
changes  of  the  papilla,  and  53  in  which  there  was  a  general  cloudiness  of  the 
same.  There  were  6  cases  of  hyperemia  of  the  papilla,  7  of  retinal  hemor- 
rhage, and  60  of  pupillary  abnormality.  Of  the  latter  there  were  25  with 
decided  differences  of  pupillary  diameter,  10  with  destroyed  reflex  to  light, 


576 


PROGRESS   OF   MEDICAL  SCIENCE. 


and  25  in  which  it  was  very  slight.  Convergence-reaction  was  almost  always 
preserved.  There  were  22  cases  of  paralysis  and  anomalies  of  the  ocular 
muscles,  4  of  partial  xerosis  of  the  conjunctiva,  29  of  congenital  anomalies 
of  the  eye,  15  cataractous  lenses,  27  corneal  opacities,  etc. 

The  second  and  concluding  article  of  Dr.  Uhthoff  (Archiv,  Band  xxxiii. 
Abth.  i.)  treats  of  the  special  aspects  of  alcohol  amblyopia,  and  of  its  relations 
with  other,  and  especially  with  tobacco  amblyopias.  We  at  last  find  some- 
thing authoritative  as  regards  the  much-mooted  question  of  the  differential 
diagnosis  between  tobacco  and  alcohol  amblyopia,  and  of  the  relative  injury 
of  the  eye  by  these  two  agents.  But  it  will  be  regretted  that  this  definiteness 
is  purely  negative.  Up  to  this  time  there  has  been  discovered  no  reliable 
ophthalmoscopic  sign  or  other  symptom  enabling  one  to  decide  in  any  given 
case.  Neither  the  living  fundus  oculi,  nor  visual  tests,  nor  anatomical  dissec- 
tion of  the  tissues,  give  any  trustworthy  answer.  The  attempt  by  Poetschke 
to  show  a  difference  in  form  of  the  central  scotoma  (paracentral  in  pure 
tobacco  amblyopia,  pericentral  in  the  alcohol  type)  is  not  found  to  hold. 

The  following,  then,  remains  the  symptom-complex  either  of  tobacco  or 
alcohol  amblyopia,  so  far  as  concerns  visual  disturbances:  There  is  central 
scotoma  for  red  and  green  in  the  great  majority  of  cases,  and  sometimes,  also, 
a  failure  in  response  to  the  same  colors  in  the  periphery.  In  a  minority  of 
cases  there  is  a  blue  scotoma,  but  it  is  less  extensive  than  the  red  and  green 
one.  In  a  very  few  cases  there  is  an  absolute  central  scotoma — i.  e.,  no  re- 
sponse to  either  color  or  light,  surrounded,  first  by  a  zone  of  blue  blindness, 
and  other  more  extended  zones  of  red  and  green  blindness.  The  periphery 
is  always  sensitive  to  white  light.  Few  exceptions  were  found  to  these  rules. 
There  was  complete  blindness  in  no  instance,  and  the  greatest  amblyopia 

(highly  exceptional)  was 

Out  of  30,000  cases  of  eye-troubles  examined  by  the  author,  there  were  204 
of  retrobulbar  optic  neuritis ;  of  these  204,  there  were  64  clearly  due  to  ex- 
cessive use  of  alcohol,  23  as  clearly  due  to  tobacco,  and  there  were  45  that 
were  either  due  to  the  combined  use  of  the  two,  or  in  which  it  was  impossible 
to  distinguish  between  the  two  agents.  3  cases  were  caused  by  diabetes, 
1  by  lead,  and  2  by  carbon  disulphide.  Of  the  remaining  cases  not  specifically 
traceable  to  toxic  agents,  syphilis  and  heredity  are  credited  with  7  each; 
multiple  sclerosis  with  5 ;  menstrual  abnormality,  3 ;  pregnancy,  4 ;  loss  of 
blood  in  abortion,  2  ;  vitium  cordis  and  periostitis,  each  1 ;  and  for  32  cases 
no  distinct  etiology  could  be  found.  Our  space  will  not  permit  consideration 
of  many  interesting  questions  treated,  such  as  the  relative  frequency  of  tobacco 
and  alcohol  amblyopia  in  different  countries,  the  differential  diagnosis  between 
these  and  other  toxic  and  systemic  forms  of  amblyopia,  etc. 


OTOLOGY. 


577 


OTOLOGY. 


UNDER  THE  CHARGE  OF 

CHAELES  H.  BUENETT,  M.D., 

PROFESSOB  OF  OTOLOGY  IN  THE  PHILADELPHIA  POLICLINIC  AND  COLLEGE  FOR  GRADUATES  IN  MEDICINE,  ETC. 


Mastoid  Operations. 

Dr.  Albert  H.  Buck,  of  New  York,  has  written  the  article  under  this 
heading,  in  the  Reference  Handbooh  of  the  Medical  Sciences  (Wm.  Wood  &  Co., 
N.  Y.). 

He  first  considers  the  so-called  Wilde's  incision,  through  the  integument  of 
the  mastoid,  down  to  the  bone,  as  one  form  of  mastoid  operation,  and  then 
the  perforation  of  the  cortex  of  the  mastoid  portion  of  the  temporal  bone,  as, 
of  course,  the  more  important  operation.  The  views  of  Schwartze,  of  Halle, 
are  alluded  to,  in  regard  to  this  operation,  and  are  accepted  in  the  main,  by 
Dr.  Buck.  Schwartze's  rules  in  regard  to  the  indications  for  the  operation 
are  as  follows : 

"1.  In  acute  inflammation  of  the  cells,  with  retention  of  pus,  if  cedematous 
swelling,  pain,  and  fever  do  not  subside  after  antiphlogosis  and  free  incision. 
2.  In  chronic  inflammation  of  the  mastoid  process  with  subacute  (periosteal) 
abscesses,  or  fistulas  in  the  mastoid.  3.  With  a  sound  cortex  of  the  mastoid, 
on  account  of  cholesteatomata  or  purulent  retention  in  the  middle  ear,  which 
cannot  otherwise  escape,  and  with  which  symptoms  arise  showing  that  the 
life  of  the  patient  is  :n  danger;  or  when  a  congestive  abscess  has  formed  in 
the  upper  posterior  wall  of  the  meatus.  4.  When  the  mastoid  appears  healthy 
and  there  is  no  pus  in  the  middle  ear,  but  when  the  mastoid  is  the  seat  of 
long-continued  and  unendurable  pain  which  other  means  fail  to  relieve. 

"  The  operation  is  of  doubtful  utility  in  old,  incurable  middle  ear  secretion, 
when  no  symptoms  of  inflammation  of  the  mastoid  or  of  purulent  retention 
in  the  middle  ear  exist.  It  is  contraindicated  when  there  are  positive  symp- 
toms of  already  existing  metastatic  pyaemia,  or  of  secondary  meningitis,  or  of 
|    cerebral  abscess." 

This  latter  rule  regarding  the  "  doubtful  utility"  of  the  operation  in  pyaemic 
cases,  is  not  accepted  by  Dr.  Buck,  because  he  holds  that  in  some  instances 
'  in  which  the  symptoms  of  meningitis  or  of  pyaemia  were  fairly  well  marked," 
the  operation  has  been  successful  in  every  way.  This  operation  is  recom- 
mended by  Dr.  Buck  in  cases  where  leeching  and  a  Wilde's  incision  fail  to 
relieve  permanently  the  pain  in  the  mastoid  region.  Operation  as  early  as  the 
sixth  day  is  recommended  in  some  cases  of  mastoid  disease,  though  "  the 
question  of  an  operation  upon  the  bone  does  not  usually  present  itself  for 
serious  consideration  before,  say,  the  tenth  day,  at  the  earliest." 

"In  all  cases  of  comparatively  recent  origin  we  must  not  forget  one  well- 
established  fact,  namely,  that  the  majority  of  them  will,  in  one  way  or  another, 
get  well  without  the  aid  of  perforation  of  the  bone."  .  .  .  "As  there  are 
no  statistics  at  hand  which  give  the  exact  proportion  of  deaths  to  recoveries 

NO.  CLXXXVIII. — OCTOBER,  1887.  37 


578 


PROGRESS   OF   MEDICAL  SCIENCE. 


among  cases  of  acute  mastoid  disease  not  treated  by  the  operative  method,  it 
is  not  possible  to  show,  by  the  statistical  methods,  exactly  how  urgent  is  the 
need  for  operative  interference."  If  delirium,  drowsiness,  or  limited  paralysis 
develop  in  a  case  in  which,  judging  from  its  history  and  from  the  conditions 
observed  in  the  ear,  we  have  already  concluded  that  perforation  of  the  mas- 
toid process  would  be  a  useful  procedure,  we  shall  certainly  be  justified  in 
stating  that  without  the  operation  the  chances  of  recovery  are  likely  to  be 
small.  It  is  in  this  latter  view  that  Buck  differs  from  Schwartze,  in  believing 
that  good  may  come  from  opening  the  mastoid  even  after  cerebral  and  pyaemic 
symptoms  have  set  in. 

Finally,  it  is  claimed  that  "  the  operation  should  be  urged  as  indispens- 
able to  life  and  health  in  those  cases  of  chronic  discharge  from  the  ear 
which  have  been  characterized  by  frequently  recurring  and  severe  attacks  of 
pain,  on  the  same  side  of  the  head,  and  in  which  an  examination  leads  us  to 
believe  that  ulcerative  action,  with  insufficient  outlet  for  the  pus  toward  the 
middle  ear  or  the  external  auditory  canal,  is  going  on  unchecked." 

Since  among  cases  of  ear  disease,  in  which  the  mastoid  process  is  more  or 
less  involved,  there  are  such  great  differences,  it  is  extremely  difficult,  in  Dr. 
Buck's  opinion,  "  to  formulate  rules  which  are  likely  to  be  of  much  use  to  one 
who  sees  mastoid  disease  rarely."  In  performing  the  operation  of  perforation 
of  the  mastoid  cortex,  and  exposing  the  antrum,  an  imaginary  line  should  be 
drawn  vertically  through  the  mastoid  tip,  and  another  at  right  angles  to  it, 
running  through  the  uppermost  boundary  of  the  external  auditory  meatus, 
and  the  perforation  made  close  beneath  the  latter,  "  as  close  to  the  meatus  as 
the  shelving  condition  of  the  bone  will  admit."  A  drill  is  preferred  to  any 
form  of  gouge,  chisel,  or  trephine  by  Dr.  Buck.  In  the  after-treatment  un- 
obstructed drainage  must  be  maintained.  Simple  antiseptic  dressings,  and 
washings  by  weak  bichloride  solutions  are  recommended.  The  injections 
into  the  wound  (antrum),  as  a  rule,  may  be  stopped  in  a  week. 

Foreign  Bodies      the  Ear. 

Usually  injections  of  warm  water  in  the  external  ear  will  be  sufficient  to 
remove  foreign  bodies  from  that  cavity.  There  occur  cases  in  which,  how- 
ever, the  surgeon  must  have  recourse  to  other  means.  And  this  has  induced 
Dr.  Charles  Delstanche,  of  Brussels,  to  publish  some  cases  occurring  in 
his  practice,  illustrative  of  removal  of  foreign  substances  from  the  ear  by 
other  methods  (Annales  des  Maladies  de  l' Oreille,  February,  1887). 

The  first  case  is  that  of  a  man,  thirty-eight  years  old,  who  used  a  feather  to 
mop  his  ear,  and  apply  to  it  a  remedy  for  chronic  otorrhcea.  When  he  was 
examined  by  Delstanche,  it  was  found  that  a  piece  of  the  feather  had  been 
forced  forward  and  downward  toward  the  Eustachian  tube  through  a  perfora- 
tion in  the  drum,  and  by  its  presence  there  had  kept  up  great  irritation  and 
inflammation  of  the  ear.  The  fragment  of  the  feather  was  removed  by  means 
of  delicate  forceps.  The  hearing  improved  at  once,  but  as  the  man  had  to 
travel  in  his  business  no  report  as  to  the  effect  on  the  otorrhcea  is  given. 

A  second  case  was  under  treatment  for  a  mastoid  abscess  involving  the 
bone,  and  accompanied  by  purulent  otorrhcea.  The  sinus  in  the  mastoid  com- 
municated with  the  drum-cavity.    A  piece  of  elastic  bougie,  1£  inches  long, 


C  TOLOGY. 


579 


was  used  as  a  drain  in  this  sinus.  Permission  was  given  to  take  the  patient, 
a  child  thirteen  years  old,  to  the  country,  on  condition  that  the  drain  was 
maintained  in  the  mastoid  fistula.  After  an  absence  of  five  months  the  patient 
was  brought  back  in  a  worse  condition,  the  directions  not  having  been  carried 
out.  The  mother  stated  that  in  the  course  of  the  first  month  after  leaving  the 
doctor,  the  piece  of  bougie  used  in  the  mastoid  fistula  became  fixed  and  she 
could  not  move  it.  In  a  day  or  two  it  disappeared  from  view,  and  the  child's 
ear  had  then  grown  worse,  and  had  run  more  profusely ;  a  small  fistula  still 
existed.  Examination  and  syringing  failed  to  detect  the  foreign  substance  in 
the  mastoid  cavity,  middle  ear,  or  Eustachian  tube.  In  three  days  after  the 
endeavors  to  find  it,  the  piece  of  elastic  tube  came  out  at  the  auditory  meatus, 
in  a  macerated  and  decomposed  state,  after  a  sojourn  of  five  months  in  the  ear. 

In  a  third  case,  a  piece  of  carrot  was  put  into  the  ear,  and  pushed  further 
in  by  tentative  means  of  extraction,  and  this  was  followed  by  cerebral 
symptoms. 

A  laboring  woman,  forty-two  years  old,  put  into  her  ear  a  piece  of  carrot 
to  cure  a  toothache  according  to  a  popular  prescription.  The  next  day, 
when  she  was  unable  to  remove  this,  she  sought  in  her  fright  a  physician, 
who  endeavored  by  dressing-forceps  to  remove  the  foreign  substance.  His 
efforts  resulted  only  in  profuse  hemorrhage  and  prolonged  syncope.  Fearing 
again  to  expose  herself  to  such  treatment  she  applied  poultices  to  her  ear, 
which  soon  became  the  seat  of  violent  inflammation  and  abundant  suppura- 
tion. Fifteen  days  after  the  event  she  was  seen  by  our  author  for  the  first 
time.  She  then  complained  of  violent  pains  in  the  ear,  accompanied  by 
tinnitus,  vertigo,  and  frequent  vomitings,  which  kept  her  in  bed.  The  tume- 
faction of  the  external  ear  was  so  great  as  to  prohibit  examination  of  the 
auditory  canal.  At  first  leeches  around  the  ear,  and  a  solution  of  lead  for 
dropping  into  the  ear,  constituted  the  treatment,  but  as  this  failed  to  change 
the  local  symptoms,  and  as  the  vertigo  and  vomiting  continued,  together 
with  intense  earache,  meningeal  complications  were  feared,  and  it  was  re- 
solved to  endeavor  to  dilate  the  auditory  canal  by  means  of  sponge-tents. 
After  allowing  a  sponge  cylinder  to  remain  a  half  hour  in  the  swollen  canal, 
the  latter  was  sufficiently  dilated  to  permit  a  view  of  the  outer  end  of  the 
piece  of  carrot.  A  portion  of  this  was  then  removed.  The  next  day,  a  sponge- 
tent  was  again  allowed  to  swell  in  the  partially  freed  canal,  and  the  rest  of  the 
carrot  was  taken  out.  It  was  found  to  be  the  tip-end  of  a  carrot,  about  one- 
third  of  an  inch  long  and  one-sixth  of  an  inch  wide,  and  evidently  had  rested 
against  the  membrana  tympani.  All  the  inflammatory  symptoms  now  ceased, 
and  in  two  days  the  membrana  could  be  seen  and  was  found  to  be  uninjured, 
though  macerated.    The  hearing  became  normal  in  a  short  time. 

In  a  fourth  case,  a  young  lawyer,  who  had  scratched  his  ear  with  a  Swedish 
safety  match,  had  at  last  perforated  the  membrana  in  its  antero-superior  quad- 
rant, and  broken  off  the  inner  end  of  the  match,  leaving  it  in  the  membrane. 
This  was  carefully  seized  by  small  forceps  under  proper  illumination,  and 
successfully  and  painlessly  removed.  It  measured  one- third  of  an  inch  in 
length  and  was  one-tenth  of  an  inch  in  diameter. 

A  fifth  case  is  a  curious  one  of  encysted  foreign  bodies  in  both  lobules  of  a 
little  girl,  twelve  years  old.  The  lobules  had  been  pierced  at  three  years  of 
age,  and  she  had  worn  ordinary  ear-rings  until  in  her  twelfth  year,  when  she 


580 


PKOGRESS   OF   MEDICAL  SCIENCE. 


had  inserted  by  a  jeweller  a  modern  form  of  ornament  consisting  in  a  jewel 
for  the  outside  of  the  lobule,  mounted  on  a  shaft,  which,  passing  through 
the  lobule,  is  held  in  position  by  a  small  screw-nut  on  the  under  surface  of 
the  lobe.  The  shafts  were  evidently  too  large  for  the  perforation,  and  caused 
inflammation  and  pain,  and,  finally,  profuse  suppuration.  The  child  was 
forced  by  her  parents  to  endure  the  pain  and  the  suppuration,  which  she  did 
for  some  weeks.  Finally,  in  two  months  the  discharge  ceased  and  the  swell- 
ing abated.  It  was  then  found  that  the  little  nuts  on  the  under  surface  of 
the  lobule  had  become  invisible.  Although  there  was  now  no  suffering,  the 
parents  alarmed  at  the  large  size  of  the  lobules,  resolved  to  remove  the  orna- 
ments which  were  still  in  situ  in  the  ears.  This  was  easily  done  by  unscrewing 
the  shafts  in  front.  These  were  removed,  but  the  nuts  remained  in  the  lobule. 
Dr.  Delstanche's  aid  was  then  sought,  because  the  lobules  seemed  to  be  getting 
larger.  He  discovered  a  round,  hard  tumor,  the  size  of  a  cherry-stone,  in 
each  lobe.  On  the  right  side  the  opening  was  healed  both  behind  and  in  front 
of  the  encysted  body,  but  on  the  left  side  the  opening  on  the  front  of  the  lobe 
persisted.  Through  this,  after  some  previous  stretching,  the  nut  was  removed. 
It  consisted  of  a  small  disk  of  gold-plated  silver,  one-tenth  of  an  inch  thick, 
and  one-sixth  of  an  inch  in  diameter,  with  a  milled  edge.  The  disk  encysted 
in  the  other  lobule  was  removed  through  an  incision  on  the  back  of  the  lobule. 

Boxing  the  Ears. 

Dr.  Samuel  Sexton,  of  New  York,  has  written  an  interesting  paper  on 
this  subject,  giving  special  attention  to  its  medico-legal  aspect  (Med.  Record, 
June  11,  1887).  It  is  claimed  that  nearly  all  blows  upon  the  side  of  the 
head  may  injure  the  ear,  and  thus  range  themselves  under  this  category.  The 
article  is  based  on  the  notes  of  fifty-one  cases,  thirty-one  being  males  and 
twenty  females.  Of  the  men,  thirteen  were  boxed  upon  the  right  ear,  and 
thirteen  upon  the  left,  and  three  of  them  upon  both  ears,  one  was  kicked  by 
a  companion  upon  the  ear  while  bathing,  and  in  one,  the  ear  was  injured  by 
having  the  head  squeezed  between  the  hands  of  another  person. 

Of  the  women,  fourteen  were  struck  upon  the  left  ear,  and  six  upon  the 
right.  Five  of  the  women  were  assaulted  by  their  husbands.  Of  the  entire 
number  of  cases,  eight  were  boxed  in  play,  four  by  rigorous  pedagogues,  two 
by  parental  disciplinarians,  and  one,  a  fervent  lover,  was  struck  on  his  ear  by 
an  indignant  sweetheart. 

Several  cases  occurred  among  pugilists,  the  left  ear  being  usually  struck  in 
cross-counter.  Others  were  due  to  assaults,  brawls,  and  contests  generally. 
Parents  ignorant  and  cruel  enough  to  box  children's  ears  are  not  likely  to 
take  them  when  injured  to  a  surgeon;  hence  the  comparatively  small  number 
of  children  brought  to  the  dispensaries  with  ears  avowedly  injured  by  boxing, 
though  a  large  number  of  those  coming  for  other  affections  of  the  ear  could 
recall  having  had  the  organ  slapped  or  pulled  previously,  and  then  having 
had  subsequently  severe  pain,  tinnitus,  and  vertigo. 

A  not  uncommon  result  of  a  blow  or  fall  upon  the  ear  is  the  impaction  of 
a  plug  of  cerumen  which  gives  rise  to  pain,  and  if  it  lie  long  in  contact 
with  the  membrana  tympani,  to  inflammation.    Rupture  of  the  drum-mem- 


OTOLOGY. 


581 


brane  in  such  cases  is  often  due  to  the  compression  of  the  air  in  the  auditory 
canal. 

The  symptoms  after  a  boxing  or  blow  on  the  ear,  are  numbness  and  auto- 
phonia  with  tinnitus.  The  patient  usually  feels  stunned,  but  in  the  entire 
fifty-one  cases  seen  by  Dr.  Sexton,  only  one  actually  Avas  felled  by  the  blow, 
and  none  were  rendered  unconscious.  The  dizziness  is  usually  brief;  pain  is 
usually  felt  immediately,  though  it  may  not  ensue  for  some  hours  as  a  re- 
active process  or  as  a  result  of  meddlesome  treatment.  Deafness  may  be 
scarcely  perceptible.  Autophonia  is  a  very  constant  symptom.  In  the  fifty- 
one  cases  under  consideration,  seven  had  no  discharge,  six  had  a  serous  dis- 
charge only,  and  in  none  of  them  were  there  any  inflammatory  symptoms. 
In  six  cases  there  was  decided  inflammation  of  the  drum  and  swelling  of  the 
drumhead,  but  no  discharge.  In  twenty-five  cases  suppurative  inflammation 
of  the  drum  occurred,  with  more  or  less  severity.  In  six  cases  particulars  on 
this  head  were  not  noted. 

The  drum-membrane  is  usually  congested,  chiefly  in  the  membrana  flaccida, 
and  on  the  malleus.  Multiple  ruptures  may  be  found,  though  usually  they 
are  solitary.  Their  shape  varies.  If  large,  they  often  heal  by  forming  a 
manometric  cicatrix.  The  prognosis  is  usually  favorable.  The  diagnosis  is 
not  difficult  if  the  ear  is  examined  early  enough,  or  before  inflammation  has 
set  in.  Ruptures  from  boxing  occur  for  the  most  part  in  the  membrana 
vibrans,  while  contusions  and  lacerations  from  pulling  the  auricle  occur  in 
the  membrana  flaccida. 

"A  differential  diagnosis  becomes  more  difficult  when  inflammation  of  the 
drum,  from  causes  other  than  traumatic,  exists  before  the  injury,  or  arises 
subsequently."  The  appearance  of  the  drumhead  a  few  days  after  traumatic 
rupture  may  suggest  a  fracture  of  the  malleus ;  but  as  the  swelling  subsides, 
it  will  appear  that  no  fracture  has  occurred. 

Treatment.  The  safe  rule,  according  to  Dr.  Sexton,  is  to  abstain  from  doing 
anything.  We  would  add,  excepting  to  protect  the  exposed  mucous  mem- 
brane by  placing  some  cotton  in  the  external  auditory  meatus.  Great  injury 
may  ensue  upon  the  instillation  of  any  fluid  into  the  canal  after  such  ruptures 
of  the  membrana  tympani. 

The  medico-legal  aspect  of  boxing  the  ear  often  becomes  an  important  one. 
But  medical  jurists  must  bear  in  mind  that  the  extent  of  aural  injury  where 
the  patient  has  been  assaulted  by  a  blow  upon  the  side  of  the  head,  is  not  to 
be  measured  by  the  force  of  contact,  but  rather  by  the  nature  of  the  blow. 
Sometimes  a  very  slight  force,  by  compressing  the  air  in  the  auditory  canal, 
ruptures  the  drum-membrane.  It  must  also  be  borne  in  mind  that  the  treat- 
ment of  the  ear,  after  the  occurrence  of  the  rupture  of  the  membrana,  has 
done  more  harm  than  the  rupture  itself,  since,  if  let  alone,  the  opening  in  the 
drum-membrane  will  soon  heal. 

It  is  very  wisely  remarked  by  the  writer  of  this  paper,  that  the  assailant  is 
not  the  only  person  to  be  held  accountable  for  the  results  of  injudicious  treat- 
ment or  neglect.  According  to  law,  if  one  suffering  physical  harm  from  the 
wrongful  act  or  omission  of  a  defendant  in  a  suit,  calls  in  good  faith  such 
medical  attendance  as  it  is  reasonable  to  presume  would  be  competent  to  effect 
his  cure  or  restoration  to  health,  and  the  physician  or  surgeon  so-called,  by 
erroneous  treatment  causes  positive  harm,  the  plaintiff  shall  nevertheless  re- 


582 


PROGRESS  OF   MEDICAL  SCIENCE. 


cover  in  the  action  for  damages.  If  the  physician's  malpractice  could  be 
established,  the  plaintiff  might  find  him,  if  pecuniarily  responsible,  a  more 
desirable  defendant  than  the  original  assailant. 

It  is  also  important  to  find  out  whether  there  has  been  deafness,  or  dis- 
charge from  the  ear,  previous  to  or  at  the  time  of  the  alleged  injury,  and  if 
so  whether  any  increase  of  the  trouble  was  caused  thereby.  This  is  a  point 
concerning  which  reliable  evidence  is  in  many  cases  either  wanting  or  diffi- 
cult to  get,  since  in  children  both  may  exist  without  the  parent's  knowledge. 

"The  question  of  permanent  injury  from  shock  is  likely  to  come  up  in  some 
cases.  Every  one  knows  that  falls  and  blows  upon  the  head  often  give  rise  to 
vertiginous  phenomena,  but  serious  labyrinthine  concussion  as  a  complication 
of  ear-boxing  is  comparatively  rare,  since  the  concussion  from  blows  with  the 
hand  or  fist  is  broken  by  the  membrana  thus  protecting  the  round  window." 
When  trauma  has  produced  purulent  inflammation  of  the  ear,  vertigo,  auto- 
phonia,  and  various  forms  of  tinnitus  as  well  as  deafness  may  remain  per- 
manently. It  is  well  to  remember  that  deafness  from  chronic  catarrh  of  the 
middle  ear  is  more  frequently  found  in  the  left  ear. 

Chronic  Purulent  Inflammation  of  the  Tympanic  Attic. 

Dr.  H.  N.  Spencer,  of  St.  Louis  [St.  Louis  Courier  of  Medicine,  May,  1887), 
having  had  a  number  of  cases  affected  with  the  above-named  disease,  has  had 
an  opportunity  of  further  studying  this  interesting  and  usually  intractable 
disease.  The  reason  this  disease  does  not  readily  yield  to  treatment  is  because 
it  is  inaccessible  to  the  ordinary  means  of  cleansing  and  medication  employed 
for  cleansing  the  lower  part  of  the  tympanic  cavity  or  atrium. 

Acute  inflammations  of  the  attic  are  characterized  by  more  intense  pain 
than  usually  accompanies  ordinary  suppurative  disease  of  the  tympanum. 
They  are  often  confounded  with  inflammation  of  the  mastoid.  Examination 
of  a  case  of  acute  inflammation  of  the  membrana  flaccida  shows  it  to  be  char- 
acterized by  intense  redness  and  tumefaction  at  the  junction  of  the  upper  wall 
of  the  canal  with  the  membrana  flaccida.  A  free  incision  with  constitutional 
phlogosis  meets  the  early  indication.  Judicious  local  treatment  and  tonics 
insure  a  good  result  in  from  one  to  six  weeks. 

The  chronic  cases  of  purulent  inflammation  of  the  attic  are  not  so  easily 
disposed  of.  This  chronic  process  may  be  limited  to  the  attic,  or  it  may  be 
associated  with  purulent  disease  in  the  atrium.  Dr.  Spencer  has  not  observed 
any  marked  tendency  of  this  disease  to  extend  to  the  mastoid  cells.  He  also 
says,  very  justly,  in  our  opinion,  that  "  either  diseases  of  the  mastoid  are  of 
less  frequent  occurrence  in  the  West  than  in  the  East,  and  less  in  this  country 
than  abroad,  or  perforation  of  the  mastoid  process  is  often  unnecessarily  per- 
formed ;  and  an  overweening  desire  to  add  to  a  number  of  operations  magnifies 
the  subjective  and  objective  indications  for  surgical  interference,  and  preju- 
dices the  otherwise  good  judgment  of  the  operator.  I  make  this  statement 
with  some  hesitation,  but  from  a  conviction  of  the  truthfulness  of  it,  so  far  as 
my  experience  has  gone,  founded  upon  upward  of  twenty-five  thousand  cases 
of  ear  disease  seen  in  private  and  hospital  practice." 

There  may  be  said  to  be  two  forms  of  purulent  inflammation  of  the  attic, 
one  characterized  by  swelling  and  a  tendency  to  poliferation  and  organization 


OTOLOGY. 


583 


of  tissue,  and  the  other  by  a  thinning  of  tissue,  or  tissue-waste.  These  forms 
are  intensified  and  rendered  more  serious  by  reason  of  the  extended  and  com- 
plicated surface  presented  by  the  attic.  This  space  and  its  contents  are,  of 
course,  functionally  of  the  greatest  importance,  as  it  contains  the  head  of  the 
malleus  and  the  malleo-incudal  joint,  and  the  entire  body  of  the  incus  except- 
ing its  long  process,  which  extends  downward  into  the  atrium.  The  opening 
by  which  drainage  takes  place  in  these  cases  is  in  the  membrana  flaccida 
(Shrapnell's  membrane).  In  very  chronic  cases,  the  membrana  vibrans,  the 
portion  below  the  folds  of  the  membrana  tympani,  will  be  found  to  have  been 
destroyed,  and  of  the  malleus  only  a  stump  will  be  found. 

In  all  of  these  conditions  of  perforation  or  destruction,  when  the  hyper- 
plastic form  of  inflammation  predominates,  the  edges  of  the  openings  and  the 
surfaces  of  the  cavity,  so  far  as  they  can  be  seen,  appear  red  and  swollen ;  not 
infrequently  there  will  be  villous  projections,  papillary  growths,  and  even 
large  polypi.  When  the  second  form,  tissue- waste,  prevails,  the  edges  of  the 
openings  are  thin  and  white,  and  the  tissues  beyond  are  characterized  by  the 
same  appearance.  The  discharge  is  often  scanty,  and  not  found  until  the 
attic  has  been  explored ;  it  is  then  apt  to  be  dark  brown  in  color.  This  second 
form  is  the  more  intractable  of  the  two,  and  is  more  likely  to  result  in  caries 
of  the  bone.  The  head  of  the  hammer,  first,  and  next  in  point  of  frequency, 
the  head  of  the  incus,  is  liable  to  become  affected  by  carious  action. 

Treatment  must  take  into  consideration  the  nature  and  locality  of  the 
lesion.  In  cases  of  suppuration  of  the  attic,  presenting  polypi  and  polypoid 
masses,  we  are  advised  "  to  curette  the  mass  or  masses  as  high  up  as  it  is 
possible  to  do  so."  An  anaesthetic  may  be  employed  or  not,  as  seems  best. 
Immediately  after  the  operation,  a  saturated  solution  of  nitrate  of  silver  is 
applied,  by  means  of  a  small  cotton  tuft  fastened  to  the  cotton-holder,  well  up 
into  the  cavity.  Dr  Spencer  has  not  found  it  necessary  to  neutralize  this, 
but  simply  dries  the  parts  with  absorbent  cotton,  in  order  to  remove  any 
excess  of  fluid.  Pain,  not  excessive,  may  follow  this  application  for  two  or 
three  hours.  Following  this  procedure,  before  the  slough  comes  away,  instil- 
lations of  absolute  alcohol,  or  a  saturated  solution  of  boric  acid  in  absolute 
alcohol,  are  recommended. 

In  the  second  class  of  cases,  referred  to  already,  the  therapeutical  require- 
ments are  different,  since  a  plastic  process  must  be  controlled.  Peroxide  of 
hydrogen  may  now  be  employed,  and  after  this  application,  a  five  per  cent, 
solution  of  carbolic  acid.  Xitrate  of  silver  may  also  be  used  in  these  cases  at 
some  part  of  the  treatment,  but  all  stimulation  must  be  of  a  mild  character. 
In  regard  to  cleansing  the  ear,  Dr.  Spencer  does  not  wash  out  the  cavity  so 
often  as  many  do,  because  he  believes  that  the  too  frequent  use  of  the  bath 
exercises  a  prejudicial  influence  upon  any  tendency  in  the  tissue  toward 
healthy  action."  He  also  believes  that  while  the  syringe  is  indispensable  at 
times,  it  may  also  become  a  means  of  doing  much  harm  by  delaying  recovery. 
"The  sooner  the  syringe  is  placed  in  the  same  category  with  the  paracentesis 
needle,  the  sharp  curette,  and  Wolfs  spoon,  to  be  employed  when  a  real  indi- 
cation exists,  the  better  for  otology  and  humanity."  For  these  cases  a  cotton- 
holder  of  steel,  and  unnotched  at  the  end,  is  recommended.  The  end  sought 
is  great  inflexibility,  the  ordinary  cotton-holder  being  too  flexible  for  the 
manipulation  here  set  forth. 


584 


PROGBESS  OF   MEDICAL  SCIENCE. 


DISEASES  OF   THE  LARYNX  AND  CONTIGUOUS 
STRUCTURES. 


UNDER  THE  CHARGE  OF 

J.  SOLIS-COHEN,  M.D., 

PROFESSOR  OF  DISEASES  OF  TIIE  THROAT  AND  CHEST,  PHILADELPHIA  POLYCLINIC. 


Mould-fungi  as  Causes  of  Diphtheria. 

Dr.  Michael  W.  Taylor  reports  cases  corroborative  of  his  theory 
that  some  common  mould-fungi,  growing  under  certain  conditions,  might 
originate  diphtheria  or  transmit  it.  These  views  are  confirmative  of  views 
long  ago  promulgated  by  Jodin,  and  to  which  too  little  attention  has  been 
given  by  more  recent  writers  on  diphtheria. 

Unusual  Cutaneous  Pigmentation  in  Diphtheria. 

Werner  (  Wurtemburg  Correspondenzblatt,  No.  7,  1887 ;  Journal  of  Laryn- 
gology and  Ehinology  for  May,  1887,  p.  169)  noted  peculiar  black  spots  on  the 
skin  of  the  under  lip  of  a  child  eight  months  of  age,  which  appeared  twelve 
to  eighteen  hours  before  death,  and  spread  diffusely.  They  reappeared  when 
brushed  away.  The  mother,  after  cleansing  the  child's  nose  and  mouth,  saw 
the  same  set  of  black  points  upon  the  back  of  her  hands,  but  could  not  re- 
move them  by  brushing.  They  resisted  applications  of  antiseptic  washes. 
Some  weeks  later  they  were  scraped  away  with  a  knife.  They  resembled  the 
spots  left  after  a  burn  with  gunpowder.  No  microscopic  investigation  was 
made  as  to  their  nature.    No  other  cases  were  observed. 

Atrophic  Ehinitis. 

Dr.  Delavan,  of  New  York,  at  the  late  session  of  the  American  Laryn- 
gological  Association,  spoke  very  encouragingly  of  treatment  by  the  galvanic 
current  with  a  force  of  from  four  to  seven  milliamperes,  the  positive  electrode 
to  the  nape  of  the  neck,  and  the  negative  one  to  the  mucous  membrane. 
His  only  objection  was  the  length  of  time  required  in  treatment.  This  is  a 
reintroduction  of  a  treatment  of  many  years  ago  practised  without  that 
insight  into  the  influence  of  electric  currents  accumulating  with  recent 
experience  and  study. 

Removal  of  Nasopharyngeal  Tumor  after  Resection  of  the 
Superior  Maxilla. 

Dr.  Nathan  Ji»  cobson,  of  Syracuse,  N.  Y.,  reports  (Proceedings  of  the 
New  York  State  Medical  Association,  1886,  reprint)  an  interesting  instance 
of  formidable  nasopharyngeal  myxosarcoma  with  prolongations  into  the  nasal 
passages,  the  antrum,  and  elsewhere,  to  remove  which  he  was  compelled  to 
resect  the  upper  jaw  chiefly  after  the  method  of  Fergusson.    The  subsequent 


LARYNGOLOGY. 


585 


rather  perilous  progress  of  this  successful  case  is  carefully  narrated ;  some 
general  remarks  follow  on  nasopharyngeal  growths  and  methods  of  treating 
them,  and  the  article  concludes  with  a  table  of  twenty-eight  similar  opera- 
tions performed  in  the  United  States,  of  which  seventeen  terminated  success- 
fully, the  result  in  two  remaining  unstated. 

Oz^ENA. 

Habermaistn,  of  Prague,  basing  his  opinion  upon  histologic  investigation 
(Zur  pathologischen  Anatomie  der  Ozsena  simplex  seu  vera.  Zeitschrift  fur 
Heilkunde,  Bd.  vii.,  Prag.,  1886  ;  Semon's  Centralblatt,  March,  1887),  concludes 
that  ozsena  simplex  consists  in  a  fatty  degeneration  of  the  glandular  epithe- 
lium, acinous  and  Bowman's,  and  apparently  of  the  epithelium  of  the  in- 
flammatorily  infiltrated  mucous  membrane.  The  transformation  of  the 
mucous  membrane  into  a  fibrous  connective-tissue  and  its  shrivelling,  he  re- 
gards as  at  first  a  result  of  this  disease,  a  result  of  the  reaction  of  the  healthy 
tissue  against  the  morbid  action  in  the  diseased  tissue.  These  changes  he 
has  not  seen  in  hypertrophic  nasal  catarrh  or  any  other  nasal  disease,  and  so 
he  regards  them  as  characteristic.  He  does  not  attribute  their  origin,  with 
Krause,  to  compression  of  the  vessels,'  but  thinks  rather  that  it  is  due  to  an 
agent  which  gradually  works  deeper  and  deeper  into  the  glandular  structures, 
because  he  finds  such  glands  diseased  in  their  excretory  orifices  and  their 
superficial  acini  while  the  deeper  parts  remain  normal.  In  the  diseased  tis- 
sues he  has  never  found  the  microorganisms  which  he  almost  always  finds  in 
the  ozsenic  secretions.  He  does  not  believe  that  hypertrophic  catarrh  is  a 
necessary  precedent  of  ozsena  simplex,  especially  as  the  histologic  conditions 
of  the  mucous  membranes  differ  in  the  two  affections. 


Tuberculous  Tumors  of  the  Nasal  Mucous  Membrane. 

Dr.  Max  Schaeffer,  of  Bremen,  and  Dr.  Dietrich  Nasse  (Deutschen 
medicinische  Wochenschri/t,  1887,  reprint)  report  eight  instances,  chiefly  in 
females,  observed  by  Dr.  Schaeffer  in  a  total  of  more  than  450  cases  of  intra- 
nasal tumors.  The  tuberculous  nature  of  the  tumors  was  proven  by  detection 
of  the  bacillus  Kochii.  All  eight  originated  in  the  septum  narium  in  its 
cartilaginous  portion  and  progressed  backward.  They  presented  in  individual 
masses,  some  of  them  as  large  as  small  walnuts,  with  uneven  raspberry-like 
surfaces.  They  varied  in  color  from  pale  to  dark  red,  bled  readily  to  the 
touch,  and  were  covered  with  purulent  mucus.  They  felt  soft  and  friable  at 
the  surface,  and  but  little  harder  toward  the  base.  Their  removal  left  a  flat 
ulcer  with  soft  wall-like  granular  edges  and  dirty  grayish-yellow  floor.  The 
underlying  cartilage  was  soft,  and  showed  great  tendency  to  destructive  de- 
generation, which,  in  three  of  the  cases,  terminated  in  perforation.  Poste- 
riorly, there  was  similar  tendency  to  disintegration  of  the  periosteum ;  and 
destruction  occurred  in  one  instance.  Six  of  the  eight  patients  had  more  or 
less  hereditary  tendency  to  tuberculosis.  In  no  instance  was  there  any  lupus 
exteriorly,  or  any  other  external  evidence  of  disease  except  knobby 
thickening  of  the  anterior  part  of  the  nose.  There  was  no  evidence  of  syph- 
ilis in  any  instance.    Laryngoscopic  inspection  and  exploration  of  the  chest 


586 


PROGRESS   OF   MEDICAL  SCIENCE. 


revealed  only  negative  conditions.  In  cases  of  long  standing,  the  morbid 
growth  had  extended  further  backward,  and  engaged  the  mucous  membrane 
of  the  middle  turbinated  body,  and  even  the  anterior  portion  of  the  mucous 
membrane  of  the  floor  of  the  nose ;  and  in  two  instances  the  opposing  surface 
of  the  lower  turbinate  was  involved,  probably  by  erosive  infection.  Three 
cases  observed  in  their  commencing  stages  left  no  doubt  that  this  form  of 
tumor  always  originates  in  the  cartilaginous  septum. 

Nasal  Vertigo. 

Dr.  Joal,  of  Mont-Dore,  has  reported  to  the  Society  Francaise  de  Laryn- 
gologie  et  d'Otologie  {Revue  Mens,  de  Laryngology,  etc.,  July,  1887)  several 
instances  showing  that  certain  vertiginous  conditions  often  attributed  to 
stomachic  and  other  influences  are  due  to  temporary  or  permanent  lesions  of 
the  nasal  passages,  curable  by  treating  the  nasal  lesion.  He  regards  the 
vertigo  as  a  genuine  reflex  result  of  the  irritation  of  the  terminal  branches  of 
the  trifacial  nerve  distributed  upon  the  mucous  membrane  of  the  intranasal 
structures  ;  a  cerebral  anaemia  being  produced  by  transmission  of  the  irritation 
through  the  sphenopalatine  ganglion  to  the  vasomotor  nerves. 

A  correspondent,  H.  D.  F.,  of  The  Lancet  (July  2,  1887,  p.  83),  states  that 
he  had  been  a  severe  sufferer  from  hay  fever  for  some  forty-five  years,  climate 
the  most  varied,  even  desert  land,  making  little  difference,  freedom  having 
been  experienced  only  during  long  sea  voyages  around  the  Cape.  At  about 
fifty-six  years  of  age,  he  suddenly  became  free,  but  with  absolute  loss  of  the 
sense  of  smell,  and  occasional  unearthly  objective  sensations  passing  into 
vertigo  and  momentary  unconsciousness.  Though  still  free  from  hay  fever, 
he  thinks  he  sneezes  more  frequently  than  most  people. 

The  Pathological  Nasal  Eeflex. 

At  the  last  annual  meeting  of  the  American  Laryngological  Association 
Dr.  John  Noland  Mackenzie,  of  Baltimore,  read  an  entertaining  histo- 
logical study  which  will  agreeably  surprise  all  our  readers  by  its  exhaustive- 
ness  and  its  references  to  show  that  Plato,  Hippocrates,  Aristotle,  Ehazes, 
Scribonius,  Largus,  Galen,  and  a  host  of  others  were  aware  of  the  connection 
between  nasal  affections  and  reflex  manifestations  at  a  distance.  The  paper, 
which  should  be  read  at  length  to  be  fully  appreciated,  appears  in  the  New 
York  Medical  Journal  of  August  20,  1887. 

Belief  of  Congestive  Headaches  by  Intranasal  Scarification. 

Dr.  Glasgow,  of  St.  Louis,  finds  (in  proceedings  of  the  American  Laryn- 
gological Association,  1887,  The  Medical  News  of  June  4,  1887)  the  cavernous 
bodies  full  and  tense  in  congestive  headaches,  the  degree  of  tension  corre- 
sponding, to  some  extent,  to  the  degree  of  headache.  For  four  years  he  has 
treated  these  cases  satisfactorily  by  local  abstraction  of  blood  from  a  simple 
prick,  relief  being  immediate  in  many  instances. 


LARYNGOLOGY. 


587 


Empyema  of  the  Antrum. 

Dr.  B.  Fraxkel,  of  Berlin  (Ueber  das  Empyem  der  Oberkieferhole,  Ber- 
liner klin.  Woch.,  1887,  No.  16),  after  laying  stress  on  the  value  of  rhinoscopy 
in  differentiating  from  diseases  of  the  antrum  certain  affections  formerly  con- 
founded with  them,  and  referring  to  Ziem's  article  (Monatschrift  fur  Ohren- 
heilkunde,  etc.,  1886,  Xos.  2  and  4),  expresses  his  opinion  that  empyema  of 
the  antrum  is  usually  an  extension  from  the  dental  alveoli,  and  only  ex- 
ceptionally, and  very  rarely  at  that,  an  extension  from  diseased  nasal  mucous 
membrane.  To  drain  the  antrum,  Frankel  prefers  perforation  through  the 
nasal  wall  to  perforation  through  the  alveolus,  because  the  latter  method 
establishes  a  communication  with  the  mouth,  and  then  the  resultant  pene- 
tration of  microorganisms,  saliva,  remnants  of  food,  and  the  like,  prolongs  the 
after-treatment  considerably.  He  prefers  to  penetrate  the  antrum  through 
the  lower  meatus,  after  the  method  described  by  Mikulicz  (Verhandlung  der 
deutschen  Gesellschaft  fur  Chirurgie,  15  Congress,  Berlin,  1886,  p.  178),  which 
avoids  the  objection  to  the  alveolar  method,  although  the  drainage  is  less 
perfect.  The  patient  is  taught  to  syringe  the  antrum  once  or  more  daily  with 
some  antiseptic  solution.  One  case  so  treated  is  reported  as  cured  in  three 
weeks,  and  three  similar  operations  are  referred  to  in  an  annotation  as  having 
proved  fully  satisfactory. 

Death  from  (Edema  of  the  Laryxx  shortly  after  Birth. 

H.  Vogt,  of  Bergen  {Norsk  Magazin  fir  Lcegevidenskaben,  Sept.  1886,  Annales 
d.  mat.  du  larynx,  etc.,  March,  1887,  and  Semon's  Centralblatt,  March,  1887), 
describes  an  instance  in  a  newborn  female,  with  generalized  anasarca  and  a 
large  and  tense  abdomen.  The  child  weighed  six  and  a  half  pounds.  It  was 
motionless  and  unable  to  respire.  The  heart-beats  were  feeble.  Death  took 
place  three-quarters  of  an  hour  after  birth.  The  autopsy  disclosed  ascites 
with  adhesions  between  the  liver  and  the  diaphragm.  The  heart,  lungs,  and 
kidneys  were  normal.  The  larynx  was  obstructed  by  an  extensive  cedematous 
infiltration  of  the  aryepiglottic  folds.  The  placenta  was  oedernatous.  The 
cause  of  the  dropsy  could  not  be  determined. 

Sudden  Death  from  (Edema  of  the  Laryxx  est  an  Adult. 

At  a  meeting  of  the  Berliner  medicinische  Gesellschaft,  May  11,  1887 
[Deutsche  med.  Woch.,  May  19,  p.  433),  Dr.  B.  Fraxkel,  of  Berlin,  presented 
a  specimen  from  a  patient  who,  when  seen  by  him,  had  been  sick  only  an 
hour,  and  with  symptoms  of  severe  dyspnoea.  Laryngoscopic  inspection  re- 
vealed serious  cedematous  tumefaction  of  the  epiglottis  and  of  the  aryepiglottic 
folds.  The  patient  was  sent  to  an  adjoining  clinic  for  tracheotomization,  but 
fell  dead  in  the  cab  on  the  passage,  without  any  asphyxic  paroxysm,  and 
without  convulsions.  Tracheotomy  was  performed,  and  artificial  respiration 
instituted,  but  without  success.  Section  showed,  in  addition  to  the  oedema  of 
the  larynx,  great  contraction  of  the  left  kidney,  the  right  kidney  being  en- 
larged and  in  a  condition  of  parenchymatous  turbidity.  Very  relaxed  heart 
with  slightly  thickened  left  ventricle.  The  oedema  of  the  larynx  seemed  to 
Franke  to  have  been  the  first  sign  of  hydremia  following  contracted  kidney. 


588 


PROGRESS  OF   MEDICAL  SCIENCE. 


No  anasarca  was  discovered  anywhere.  Considerable  albumen  was  found  in 
the  urine  present  in  the  bladder  after  death.  Virchow  raised  the  question 
whether  the  case  had  not  been  one  of  erysipelas,  and  in  the  recent  session  of 
the  Society  Frankel  was  enabled  to  answer  in  the  negative,  as  the  result  of 
microscopic  investigation  for  erysipelas  cocci.  He  had  found  an  inflam- 
matory condition  which  might  have  accounted  for  the  oedema. 

Topical  Cures  of  the  Tuberculous  Larynx. 

At  a  meeting  of  the  Soc.  med.  des  hopitaux  of  Paris,  held  May  13,  1887 
(Le  Progrhs  Medical,  Mai  21,  1887,  p.  428),  Prof.  Gougexheim  reported 
twenty-five  instances  of  cure  of  tuberculosis  of  larynx,  pharynx,  etc.,  by  the 
method  of  Krause  as  practised  by  Hering,  namely,  energetic  friction  with 
strong  solutions  of  lactic  acid,  in  some  instances  after  preliminary  scraping 
or  scarification.  In  thirteen  cases  of  tuberculosis  of  lungs  and  larynx  a 
definitive  cure  was  procured  in  from  three  to  twelve  months.  In  nine  others 
recurrence  ensued  after  cure  of  the  preceding  local  tuberculosis,  and  re- 
cicatrization  took  place  in  three  of  these.  There  were  six  instances  of  cure 
in  cases  of  ulcerations  of  the  pharynx,  the  tongue,  and  the  nose. 

SWALLOWIXG-  EEXDERED  EASY  IX  TUBERCULOSIS  OF  LARYXX. 

Under  this  head  {The  Lancet,  July  2, 1887,  p.  13)  Dr.  R.  Norris  Wolfex- 
dex,  of  London,  calls  attention  to  a  method  of  swallowing  adopted  by  one  of 
his  patients  by  which  the  subjects  of  laryngeal  phthisis  can  readily  drink  even 
large  quantities  of  fluids.  The  patient  placed  himself  on  a  couch  stomach 
downward,  with  the  head  and  arms  hanging  free  over  the  end,  and  with  the 
feet  higher  than  the  other  portions  of  the  body.  He  then  placed  a  section  of 
rubber  tubing  six  inches  in  length  in  a  tumbler  of  water  held  between  both 
hands,  and  with  the  free  end  of  the  tube  between  his  lips  drained  the  contents 
off  without  stopping,  and  with  the  greatest  ease  and  comfort,  and  without 
pain  or  cough.  In  the  ordinary  position  a  teaspoonful  of  fluid  was  as  much 
as  he  could  manage  to  get  down,  and  this  only  at  the  cost  of  much  pain  and 
terrible  paroxysms  of  cough. 

Lupus  of  the  Laryxx. 

Dr.  Micha.ee  Grossmaxx,  of  Vienna  (Ueber  Lupus  des  Kehlkopfes,  des 
harten  und  weichen  Gaumens  und  des  Pharynx,  Medlzinische  Jahrbilcher  der 
h.  h.  Gesellschaft  der  Aerzte  in  Wien,  1887,  iv.  Heft,  S.  186,  illustrated  by 
chromolithographs)  in  an  interesting  summary  reports  two  cases,  one  of  which 
was  reported  in  1877  ( Allg.  Wien.  med.  Ztg.,  1877,  No.  xx.),  and  has  been 
under  his  observation  ever  since. 

I.  J.  W.,  a  ten  year  old  boy,  lived  for  six  years  in  a  musty,  damp  dwelling, 
and  left  it  in  his  seventh  year  with  moderate  lymphatic  tumefaction  in  the 
left  submaxillary  region.  Following  suppuration  undoubted  lupus  vulgaris 
began  in  the  edges  of  the  ulcer,  and  eventually  involved  the  entire  skin  of  the 
region.    Two  months  after  the  earliest  appearance  of  lupus  in  the  skin,  the 


LARYNGOLOGY. 


589 


boy  began  to  be  hoarse  at  night  without  any  special  exposure  and  without 
any  special  suffering.  On  laryngoscopic  inspection,  movement  was  found 
almost  unimpaired,  and  nothing  abnormal  was  noticed  except  general  hyper- 
emia of  the  larynx.  The  child  was  reexamined  two  or  three  times  a  week  at 
first,  and  then  nearly  every  day.  Nothing  but  the  hyperemia  was  noted  for 
nearly  two  months,  despite  daily  progressive  loss  of  voice  to  actual  aphonia, 
and  there  was  no  local  suffering.  In  the  fifth  week  severe  spasmodic  cough 
set  in,  especially  at  night.  From  that  time  onward,  the  laryngoscopic  picture 
changed  from  day  to  day.  The  mucous  membrane  of  both  surfaces  of  the 
epiglottis,  of  the  arytenoid  cartilages,  and  the  interarytenoid  fold  acquired 
the  appearance  of  a  pronounced  trachoma  of  the  conjunctiva.  The  deeply 
injected  mucous  membrane  had  lost  much  of  its  pellucidness,  and  its  surface 
was  closely  overlaid  with  granulations  varying  in  dimensions  from  small 
poppy  to  milletseeds.  A  few  days  after  this  condition  had  been  noted,  the 
same  conditions  ensued  on  the  soft  and  hard  palate.  This  condition  continued 
unchanged  for  from  two  to  three  weeks.  At  about  the  fourth  week  the  free 
border  of  the  epiglottis  began  to  get  more  uneven,  thick,  and  plump,  and 
instead  of  the  original  soft  granulated  surface,  a  greater  confluence  of  these 
granulations  took  place.  In  this  manner  strongly  prominent  and  intensely 
injected  nodules  were  formed.  The  same  thing  occurred  in  the  hard  and  soft 
palate.  In  both  localities  the  top  of  the  protruding  nodules  underwent  first 
an  epithelial  and  then  in  a  few  days  a  deeper  loss  of  substance,  establishing 
ulcers.  While  spontaneous  cicatrization  would  be  going  on  in  these  ulcerations, 
fresh  ulcerations  would  be  produced  in  other  places  in  the  same  manner. 
Often  two  or  more  contiguous  ulcerations  would  coalesce  into  a  single  exten- 
sive one.  This  process  of  ulceration  and  cicatrization  took  place  in  the 
different  portions  of  the  larynx,  hard  and  soft  palate,  without  producing  any 
impediment  in  swallowing  or  any  other  trouble.  At  the  end  of  about  a  year, 
a  swelling  began  in  the  anterior  portion  of  the  posterior  wall  of  the  larynx, 
which  increased  from  day  to  day,  and  within  five  or  six  weeks  projected  into 
the  interior  of  the  larynx  as  a  tumor,  and  covered  two-thirds  of  the  glottis, 
producing  considerable  dyspnoea  at  night,  much  slighter  in  the  waking  condi- 
tion. After  some  cauterization  with  lactic  acid  under  cocainization,  to  relieve 
the  dyspnoea,  the  swelling  underwent  spontaneous  diminution  for  a  time. 
Treatment  by  lactic  acid  has  been  continued  with  satisfactory  results,  the 
morbid  processes  subsiding  much  more  rapidly  than  they  do  spontaneously. 

II.  This  was  in  a  twenty-seven  year  old  female,  under  Neumann's  care, 
with  primary  lupus  of  the  left  conjunctiva  and  eyeball,  with  extension  to  the 
wing  of  the  nose  and  upper  lip.  In  talking  to  her  (1877)  Grossman  noticed 
that  she  was  hoarse,  and  on  questioning  her  found  she  had  always  been  hoarse. 
There  was  a  large  heart-shaped  defect  in  the  central  portion  of  the  epiglottis; 
the  vocal  and  ventricular  bands  uneven,  knobby,  and  covered  moderately  with 
granulations,  with  a  tag  of  similar  tissue  beneath  the  anterior  commissure  of 
the  vocal  bands.  No  abnormity  was  seen  in  the  mouth  or  throat,  except  a 
cicatricial  distortion  of  the  uvula.  During  the  ensuing  ten  years  the  laryngo- 
scopic appearance  has  hardly  changed,  but  the  hard  and  soft  palate,  and  par- 
ticularly the  pharynx,  have  become  implicated. 


590 


PROGRESS  OF   MEDICAL  SCIENCE. 


Cysts  of  the  Larynx. 

In  the  Annates  des  Maladies  de  V  Oreille,  du  Larynx,  June  and  July,  1887, 
is  published  a  paper  read  by  Dr.  J.  Garel,  of  Lyon,  to  the  Societe  de 
Laryngologie,  April,  1887.  He  reports  sixteen  cases  out  of  a  total  of  sixty 
laryngeal  neoplasms  seen  by  him ;  a  proportion  so  largely  in  excess  of  the 
usual  experience  as  to  suggest  the  suspicion,  were  it  not  for  the  conclusive 
character  of  the  reports,  that  most  of  them  had  been  examples  of  masses  of 
pellucid  mucus  adherent  to  the  vocal  bands.  Attention  may  be  called  in  this 
connection  to  the  circumstance  that  cysts  of  the  larynx  have,  as  a  rule,  been 
found  much  more  frequently  on  the  right  side  of  the  body,  in  contradis- 
tinction to  the  preponderance  of  other  neoplasms  on  the  left  side. 

Laryngeal  Polyp  Removed  with  the  Finger-nail 

AFTER  LARYNGOFISSURE. 

Dr.  Franz  Schopf  (Aerz.  Bericht  d.  off.  Bezirker-Krankenhauses  in 
Sechshaus  fiir  1875,  Wien,  1886  ;  Semori's  Centrallblatt  for  March,  1887,  p.  321) 
reports  a  polyp,  the  size  of  a  bean,  located  below  the  glottis.  Dyspnoea ; 
tracheotomy;  laryngoscopy  very  difficult.  Laryngofissure ;  polyp  soft,  and 
removed  with  the  finger-nail.  Wound  in  larynx  healed  by  first  intention. 
Canula  removed  after  a  month.  Voice  better,  but  still  deep-toned.  Breathing 
free.  Recovery. 

Pachydermia  Laryngis. 

In  the  Berliner  klinische  Wochenschrift  of  August  8th  is  published  a  lecture 
by  Virchow  on  pachydermia  laryngis.  He  calls  attention  to  the  fact  that 
squamous  epithelium  covers  the  mucous  membrane  located  between  the  ary- 
tenoid cartilages  and  continues  uninterruptedly  forward  upon  the  vocal 
bands  to  their  anterior  extremities.  This  portion  of  mucous  membrane,  like 
the  squamous  covered  mucous  membrane  of  the  mouth,  pharynx,  and  oesoph- 
agus, closely  resembles  the  epidermoidal  layers  of  the  skin ;  that  is  to  say, 
it  possesses  a  more  or  less  cutaneous  or  dermoid  character.  The  dermoid  por- 
tions of  the  larynx  are  not  provided  with  glands;  they  have  a  relatively  dry 
quality ;  they  furnish  none  of  the  copious  secretion  observed  in  their  imme- 
diate proximity;  in  short,  they  represent  a  domain  of  their  own.  In  this 
region  a  number  of  processes  are  evolved  which  are  not  evolved  in  the  same 
way  on  those  surfaces  which  are  clothed .  in  the  usual  manner  with  ciliary 
epithelium  and  which  possess  the  character  of  mucous  membrane  in  its  re- 
stricted sense. 

There  are  two  varieties  of  changes  in  chronic  inflammatory  processes  in  the 
larynx  which  so  greatly  exceed  the  ordinary  volume  of  simple  chronic  catarrh, 
that  they  must  be  separated  therefrom.  In  both  varieties  a  greater  quantity 
of  squamous  epithelium  is  formed.  In  one  this  is  the  chief  change ;  not  only 
quantitatively,  but  because  the  longer  the  process  continues  the  more  the  epi- 
thelium acquires  an  epidermoidal  character.  In  the  other  the  changes  occur 
more  in  the  superficial  layers  of  connective  tissue,  that  is  to  say,  in  the 
mucous  membrane  proper.  The  latter  produces  a  more  diffuse  swelling;  the 
former  is  circumscribed  in  individual  and  usually  very  small  points. 


LARYNGOLOGY. 


591 


By  virtue  of  the  dermoid  character  of  the  affected  parts  Virchow  has  long 
been  accustomed  to  group  all  these  processes  under  the  name  pachydermia. 
Thus  there  are  two  different  forms  of  pachydermia  laryngis;  one  diffuse  in 
which  a  tumefied  condition  of  mucous  membrane  prevails,  a  relatively  smooth 
form;  the  other  limited  to  small  places,  more  circumscribed  and  which  he 
calls  warty  (pachydermia  verrucosa). 

The  term  papilloma  is  a  misnomer  and  is  not  used  by  Virchow.  He  would 
gladly  see  it  expunged  from  literature.  As  the  growth  is  a  development  and 
hardening  of  the  epithelium,  it  should  properly  be  termed  epithelioma,  a 
term  already  misapplied  to  a  certain  variety  of  cancer.  Scientifically  the 
term  epithelioma  should  indicate  that  form  of  tumor  in  which  epithelium 
predominates,  and  epithelioma  should  be  divided  into  the  hyperplastic 
variety  which  is  formed  from  like  tissue,  and  the  heteroplastic  variety  which 
occurs  in  unlike  tissue.  According  to  Virchow's  view,  warts  of  the  larynx 
are  of  epithelial  nature.  Formerly  they  were  called  quite  correctly  condy- 
loma, but  this  term  is  now  otherwise  interpreted  in  medicine  and  cannot, 
therefore,  be  intelligently  applied.  The  only  name  which  cannot  be  mis- 
understood is  hard  wart  (verucca  dura  seu  cornea). 

Curiously  enough  these  warts  or  papillomas  have  been  scientifically  assigned 
to  the  fibromas,  but  this  is  a  great  error.  The  connective  tissue  forms  too 
little  a  contingent  to  justify  the  name  fibroma. 

Virchow's  distinction  between  papillary  warts  and  papillary  cancer  is  this: 
He  considers  all  these  as  benign,  simple,  local,  and  only  superficially  hyper- 
plastic in  which  the  sharp  normal  demarcation  is  found  at  the  base  of  the 
epithelial  layer.  Any  trace  of  epithelium  in  the  connective  tissue  he  regards 
as  suspicious.  Neither  a  flat  swelling  nor  a  papillary  growth  should  contain 
anything  below  the  boundary  line  which  belongs  to  the  domain  of  epithelial 
formations ;  all  this  must  lie  outside  of  and  beyond  the  connective  tissue  line. 

Epithelial  formations  beneath  the  boundary  line  he  considers  cancerous. 
It  is,  therefore,  important  to  examine  carefully  the  base  of  a  morbid  growth 
before  it  is  submitted  to  section,  and  even  before  hardening.  Otherwise 
spaces  between  the  papillae  may  be  mistaken  for  alveoli  with  epithelial  con- 
tents. If  there  is  nothing  foreign  at  the  base  of  the  growth,  then,  no  matter 
what  may  be  found  on  the  free  surface,  it  is  a  local  formation  of  benign  char- 
acter from  which  nothing  malignant  will  be  developed  later. 

The  question  of  recurrence  has  nothing  to  do  with  this  examination.  That 
recurrence  may  take  place  is  fully  established.  A  new  formation  may  take 
place  close  to  the  cicatrix  marking  the  seat  of  a  previous  growth,  but  by  re- 
peated removals  even  the  last  vestige  may  be  definitively  disposed  of.  That 
such  warts  may  subside  of  themselves  like  warts  of  the  skin  has  been  main- 
tained by  many  who  believe  to  have  seen  instances.  Warts  on  the  hands 
have  usually  only  a  certain  duration.  If  they  remain  a  long  time  they 
usually  drop  off  even  when  they  have  not  been  violently  attacked. 

Accidental  Intubation  of  the  Larynx  in  the  Passage  of  the 

Stomach  Tube. 

Dr.  Coustoux,  of  Nantes,  reports  [Annates  des  Maladies  de  V  Oreille,  du 
Larynx,  etc.,  July,  1887,  p.  320)  in  detail  an  instance  of  this  accident  from 


592 


PROGRESS  OF   MEDICAL  SCIENCE. 


which  he  draws  the  inference  that  it  would  be  prudent,  after  passing  a  stomach 
tube,  to  ask  the  patient  some  question  so  that  his  answer  would  give  phona- 
tory  evidence  that  the  tube  was  not  in  the  larynx,  as  otherwise  injections 
might  be  made  which  would  produce  suffocation. 

Intubation  of  the  Larynx. 

Prof.  Carl  Stork,  of  Vienna  (  Wiener  medicinische  Presse,  No.  12,  March 
20,  1887),  speaks  very  favorably  of  intubation,  and  illustrates  an  improved 
instrument  designed  by  him  for  introduction  and  withdrawal  of  the  tube, 
which  he  considers  superior  to  the  appliance  of  O'Dwyer  for  that  purpose. 
This  instrument,  an  illustration  of  which  can  also  be  seen  in  the  Journal  of 
Laryngology  and  Rhinology  for  June,  appears  to  be  modelled  on  the  trivalve 
tracheal  dilator  of  Laborde,  the  middle  branch  being  formed  on  three  links, 
the  terminal  one  of  which  is  provided  with  a  detachable  pear-shaped  ex- 
tremity, and  the  lateral  branches  terminating  in  cup-shaped  extremities  then 
enclose  it. 

Interesting  papers  on  Intubation  were  read  at  the  recent  annual  session  of 
the  American  Laryngological  Association  by  Drs.  Ingals,  of  Chicago,  and 
Sajous,  of  Philadelphia  {New  York  Medical  Journal,  June  11,  1887). 

The  former,  whose  personal  experience  has  been  extensive,  called  special 
attention  to  feeding  patients  as  little  as  possible  after  intubation,  and  avoiding 
liquid  nourishment  as  much  as  possible,  to  prevent  complications  from  escape 
of  food  into  the  air-passages.  This  paper  constitutes  an  excellent  summary 
of  the  entire  subject,  and  is  replete  with  details  valuable  to  all  who  may  have 
occasion  to  practise  the  operation.  Dr.  Sajous'  paper  occupies  much  similar 
ground  ;  but  its  essential  feature  is  in  the  presentation  of  a  peculiarly  formed 
tube  constructed  to  overcome  the  several  difficulties  occasioned  by  the  tube  of 
O'Dwyer,  and  of  a  special  appliance  for  its  readier  introduction  and  removal. 
The  discussion  upon  these  papers  cordially  endorsed  the  method  as  a  frequent 
substitute  for  tracheotomy. 

Laryngectomy. 

Three  additional  laryngectomies  by  Hahn,  of  Berlin,  for  carcinoma  are 
reported  by  Cohn  {Deutschen  medicinische  Wochenschrift  of  June  2,  p.  470), 
two  complete  and  one  unilateral.  Of  Hahn's  9  total  extirpations  previous 
to  these,  2  are  dead  from  recurrence,  1  a  sarcoma,  at  six  and  four  months 
after  operation.  1,  seventy-five  years  of  age,  is  well  seven  years  after  opera- 
tion :  and  another,  still  living,  is  in  a  condition  of  recurrence.  Of  the  entire 
10  cases  of  total  extirpation,  4  died  within  a  few  weeks,  1  of  erysipelas,  1  of 
mediastinitis,  1  of  pleuritis  and  pulmonary  gangrene,  and  1  of  pneumonia. 
Of  the  4  partial  exsections,  2  for  carcinoma,  none  died  from  the  operation. 
In  1  case  recurrence  took  place  within  four  months,  and  the  extirpation  of 
the  larynx  had  then  to  be  made  complete. 

A  Modified  Laryngectomy. 

At  the  recent  session  of  the  American  Laryngological  Association,  Dr.  J. 
Solis  Cohen,  of  Philadelphia,  suggested  {New  York  Medical  Journal  of  June 


LARYNGOLOGY 


593 


18,  1887)  that  in  many  instances  in  which  the  larynx  is  removed  entire,  the 
same  purpose  will  be  equally  accomplished,  and  with  far  less  risk  to  life,  by 
simply  removing  with  the  soft  parts  so  much  of  the  anterior  wall  of  the  thy- 
roid cartilages  as  is  necessary  to  insure  the  complete  removal  of  the  respira- 
tory contingent,  leaving  the  wings  of  the  thyroid  cartilages  almost  intact  and 
with  their  anatomical  connections  undisturbed. 

Aneurismal  Pressure  on  Pneumogastric  and  Recurrent 
Laryngeal  Nerves. 

Dr.  David  Newman,  of  Glasgow,  in  a  lecture  on  some  points  in  relation 
to  the  Diagnostic  Significance  and  Therapeutic  Indications  of  Laryngeal 
Symptoms  resulting  from  pressure  of  aneurisms  upon  the  vagus  and  recurrent 
laryngeal  nerves  {British  Medical  Journal  of  July  2,  1887,  p.  1)  describes  four 
cases  from  the  records  of  which  he  desired  to  show  :  First,  that  aneurism  of  the 
aorta  and  innominate  artery  may  exist  and  give  rise  to  laryngeal  symptoms 
only  ;  but  in  most  instances,  on  critical  examination,  certain  collateral  signs 
may  be  made  out  sufficient  to  warrant  one  in  forming  a  positive  diagnosis,  or 
to  give  rise  to  a  very  strong  suspicion  of  an  intrathoracic  tumor.  Second,  that 
in  the  early  stage  pressure  may  cause  paroxysms  of  most  urgent  dyspnoea, 
accompanied  by  laryngeal  stridor  and  paroxysmal  cough.  Third,  that  at  a 
later  stage  paralysis  occurs  usually,  but  not  always,  limited  to  one  side,  char- 
acterized by  phonative  waste  of  breath  and  imperfect  cough,  but  without 
dyspnoea,  except  when  reflex  spasm  is  indicated  on  the  opposite  side,  or  when 
pressure-stenosis  is  caused  by  the  aneurism.  Fourth,  that  in  certain  cases 
tracheotomy  should  be  performed,  not  only  to  prevent  impending  death  from 
asphyxia,  but  also  as  a  remedial  measure. 

The  recommendation  of  tracheotomy  as  a  remedial  measure  in  cases  in 
which  the  paroxysms  of  dyspnoea  are  due  to  laryngeal  obstruction  and  not  to 
actual  pressure  on  the  trachea,  is  mainly  based  upon  personal  experience, 
clinical  and  pathological,  to  the  effect  that  in  a  large  number  of  cases  of 
aneurism  death  by  hemoptysis  is  pieceded  by  threatenings  of  laryngeal  suf- 
focation, while  the  rupture  of  the  sac  has  in  many  cases  been  directly  caused 
by  the  spasmodic  attacks  of  dyspnoea. 

Topical  Medication  of  the  Trachea  and  Bronchi. 

Dr.  Max  Schaeffer,  of  Bremen  [Monatss'chrift  fur  OhrenheilJcunde,  etc., 
No.  4,  1887),  has  noticed  the  similarity  of  asthmatic  dyspnoea  with  that  pro- 
duced by  the  introduction  of  medicaments  into  the  trachea.  The  patients 
think  they  do  not  have  enough  air  in  the  lungs,  and  make  inspiratory  efforts 
in  consequence ;  and  then,  when  the  trachea  and  bronchi  become  overfilled, 
they  swallow  air  into  the  stomach.  The  compressed  air  in  the  trachea  and 
bronchi  excites  spasm  of  the  glottis  by  irritating  the  inferior  surface  of  the 
vocal  bands.  The  patient  springs  up  with  cold  perspiration  on  his  face,  and 
clutches  his  throat  anxiously.  Finally  the  irritation  on  the  vocal  bands  be- 
comes too  great,  the  bands  separate  by  mechanical  pressure,  most  likely,  and 
the  air  escapes  noisily  from  trachea  and  bronchi,  and  then  from  trsophagus 
and  stomach.    With  crackling  eructation  the  patient  experiences  relief,  and 

NO.  CLXXXV1II. — OCTOBER,  1887.  38 


594 


PKOGKESS  OF   MEDICAL  SCIENCE. 


a  deep  inspiration  convinces  him  that  he  is  not  going  to  choke  to  death. 
Schaeffer's  success  with  electrization  in  asthmatic  paroxysms  led  him  to  treat 
spasm  of  the  glottis,  from  introduction  of  medicaments,  in  the  same  manner. 
He  places  the  electrodes  of  a  strong  current  of  induction  upon  both  sides  of 
the  larynx,  and  controls  the  spasm  at  once.  Believing  that  such  spasm  is 
more  or  less  an  expiratory  dyspnoea,  he  endeavors  to  prevent  its  occurrence 
by  the  following  method  of  manipulation :  The  patient  is  to  take  a  deep  breath 
while  the  mirror  is  being  placed  in  position  ;  he  is  made  to  say  eh  while  the 
insufflator  or  syringe  is  being  introduced ;  and  then  the  medicament  is  pro- 
pelled during  an  inspiratory  phase  of  a  quiet  respiration.  With  children,  he 
applies  powders  through  the  nose  during  an  inspiration  with  the  mouth  closed, 
and  these  powders  reach  at  least  the  upper  portion  of  the  trachea, 

Carcinoma  of  the  Thyroid  Gland,  and  its  Typical  Anatomical 

Course. 

An  autopsical  study  of  a  carcinomatous  tumor  of  the  thyroid  gland  has  led 
Dr.  D.  Aigre,  of  Boulogne-sur-Mer  {Revue  Mensuelle  de  laryngologie,  etc., 
June,  1887,  p.  304)  to  some  shrewd  clinical  and  anatomical  observations  which 
merit  abstract  with  some  detail.  The  tumor  in  question  involved  the  left  lobe, 
which  passed  completely  around  the  pharynx  and  oesophagus,  in  front  of  the 
prevertebral  connective  tissue,  and  rejoined  the  extremity  of  the  healthy  right 
lobe.  Slight  involvement  of  the  trachea  existed  in  the  form  of  two  small 
hernia-like  polypoid  productions  at  the  anterior  segment  of  the  third  ring. 
The  oesophagus  was  pushed  curvilinearly  considerably  to  the  right,  its  external 
surface  being  inseparable  from  the  tumor  and  involved  in  its  substance,  pre- 
senting interiorly  a  limited  circle  of  softened  mucous  membrane,  with  slight 
inequalities  and  numerous  anfractuosities  and  one  partially  detached  pear- 
shaped  excrescence  the  bulk  of  a  small  nut.  The  left  carotid  was  slightly 
displaced,  but  otherwise  normal.  The  primitive  left  jugular  was  distended 
to  the  size  of  a  little  finger,  and  filled  with  readily  detachable  neoplasmic 
tissue  similar  to  that  of  the  tumor ;  and  one  of  the  thyroid  veins  was  similarly 
enlarged  and  filled  with  the  same  kind  of  tissue.  The  right  recurrent  laryngeal 
was  normal ;  the  left  one  could  not  be  traced  beyond  the  inferior  limit  of  the 
tumor. 

In  studying  the  features  of  this  case  in  connection  with  six  others  reported 
in  literature  since  the  publication  of  Krishaber's  monograph  in  1882  {Annates 
Mai.  de  Voreille  du  larynx,  etc.,  Nov.  1882),  Dr.  Aigre  finds  some  errors  and  some 
omissions  in  the  classic  descriptions  given  by  general  authors.  Thus,  as  to 
the  precocious  acute  pains  irradiating  along  the  neck  and  upper  limb,  believed 
to  be  sufficiently  constant  to  constitute  an  important  element  in  differential 
diagnosis,  they  were  affirmed  to  be  absent  in  three  of  the  seven  alluded  to, 
and  not  mentioned  at  all  in  the  accounts  of  the  other  four.  Instead  of  death 
by  the  cancerous  cachexia,  as  described  by  general  authors,  death,  in  these 
seven  cases,  took  place  three  times  by  dyspnoea,  once  by  dysphagia,  once  by 
repeated  hemorrhage,  and  once  by  intercurrent  nephritis.  It  appears  that 
the  thyroid  gland  shares  with  its  neighboring  organ,  the  larynx,  an  immunity, 
as  a  rule,  from  carcinomatous  generalization. 

Though  obliteration  of  the  primitive  jugular  vein  is  so  frequent  as  to  be 


DEEMATOLOGY. 


595 


almost  always  cited,  there  is  no  record  of  any  phenomena  of  cerebral  stasis 
due  to  obstruction  to  the  blood-current ;  nor  is  there  any  mention  of  abnormal 
development  of  the  anterior  jugular  or  the  vertebral,  which  act  as  compen- 
sators, without  enlargement. 

The  encircling  of  the  trachea  and  oesophagus,  so  frequent  in  these  tumors, 
and  the  easy  separation  of  the  mass  from  the  other  tissues  with  which  it  is  in 
immediate  relation,  struck  Dr.  Aigre  as  typical,  and  led  him  to  make  some 
anatomical  investigations  which  confirmed  the  special  description  of  the  con- 
nections of  the  thyroid  gland  given  by  Sappey,  but  by  no  other  anatomist,  and 
which,  in  his  opinion,  accounts  for  the  peculiarities  in  the  course  taken  by 
the  cancerous  thyroid.  Aigre's  researches  on  cadavers  of  different  ages,  sexes, 
and  plumpness,  gave  uniform  results,  as  follows :  The  thyroid  gland  being 
exposed  enclosed  in  its  capsule,  it  is  found  very  easy  to  isolate  the  vasculo- 
nervous  mass  with  which  it  is  in  relation  by  an  intermediate  layer  of  connective 
tissue,  and  thus  to  get  down  to  the  prevertebral  aponeurosis.  From  this  apo- 
neurosis the  cesophagothyroidean  mass  can  be  readily  separated  with  the 
handle  of  the  scalpel.  This  separation  being  made  to  a  certain  extent,  the 
thyroid  gland,  the  trachea,  and  the  oesophagus  can  be  removed  en  masse  by 
means  of  two  transverse  sections,  one  above  the  hyoid  bone,  the  other  at  the 
level  of  the  sternal  notch.  If  this  mass  be  turned  over  and  a  vertical  incision 
be  made  in  the  middle  line  of  the  posterior  face  of  the  oesophagus,  a  thin 
fibrous  membrane  may  be  lifted  with  the  forceps  and  be  detached  from  the 
longitudinal  musculature  of  the  oesophagus,  and  then  be  dissected  off  on  the 
two  sides  as  far  as  the  posterior  border  of  the  lobe  of  the  thyroid.  At  this 
point  the  fibrous  layer  doubles  to  envelop  the  proper  tissue  of  the  thyroid 
gland  in  continuance  with  its  fibrous  capsule.  This  disposition  of  the  layers 
of  connective  tissue  controls,  according  to  Aigre,  the  direction  followed  by  the 
neoplasm. 


DERMATOLOGY. 


UNDER  THE  CHARGE  OF 

LOUIS  A.  DUHRING,  M.D., 

PROFESSOR  OF  DERMATOLOGY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA. 

AND 

HENRY  W.  STELWAGON,  M.D., 

PHY8ICIAN  TO  THE  PHILADELPHIA  DISPENSARY  FOR  SKIN  DISEASES. 


The  Etiology  of  Impetigo,  Furuncle,  and  Sycosis. 

According  to  the  investigations  and  interesting  experiments  of  Bockhart 
{Monatshefte  fur  praktische  Dermatologie,  No.  10,  1887),  the  diseases  known  as 
sycosis,  furuncle,  and  impetigo,  are  due  to  the  same  cause — the  presence  of 


596 


PROGRESS  OF  MEDICAL  SCIENCE. 


the  Staphylococcus  pyogenes  aureus  and  albus.  In  every  case  of  these 
diseases  the  author  was  able  to  find  these  micrococci  in  great  numbers.  In 
some,,  though  few  lesions,  one  only  of  the  two  above  varieties  was  found, 
while  in  most  instances  the  two  were  indifferently  present.  In  personal  in- 
oculations the  results  were  in  accordance  with  the  clinical  investigations. 

Leprosy  and  Vaccination. 

In  the  British  Medical  Journal  of  June  11,  1887,  Gairdner  reports  two 
cases  of  leprosy,  both  of  which  were  apparently  consequent  upon  inoculation 
through  vaccination.  A  physician,  practising  at  a  well-known  endemic  seat  of 
leprosy,  vaccinated  his  son  with  the  crust  obtained  from  a  healthy  child  in  a 
leprous  family  in  whom  leprosy  subsequently  showed  itself.  Using  his  own 
child  as  a  vaccinifer,  he  vaccinated  the  child  of  a  Scotch  sea-captain.  Later 
his  own  child  exhibited  symptoms  of  the  disease,  in  a  mild  form,  while  the 
son  of  the  sea-captain  developed  the  disease  in  its  rapid  and  worst  type. 

Pruritus  Hiemalis. 

Payne  reports  {British  Medical  Journal,  May  7.  1887)  several  cases  of  the 
more  severe  type  of  this  affection,  and  adds  his  experience  on  the  subject  of 
treatment.  Unfortunately  the  disease  is  difficult  to  manage,  and  usually 
palliation  only  is  to  be  anticipated.  The  underwear  should  be  soft  and  un- 
irritating;  soft,  pure  woollen  should  be  worn  ;  not  the  coarse,  rough,  irritating 
woollen  mixtures  which  are  generally  sold.  The  skin  should  be  protected  by 
an  oily  or  viscid  lubricant.  This  permeates  the  epidermis  and  makes  it  a 
more  perfect  non-conductor,  and  the  cutaneous  nerves  are  thus  better  shielded 
against  temperature  variations.  The  author  has  had  best  results  with  glycerin 
lotions.    Internally  chloral  was  occasionally  administered  at  night. 

Naphthol. 

Attention  is  again  directed  (Medical  Record,  May  21,  1887)  to  the  use  of 
naphthol  in  cutaneous  diseases  by  Allen.  The  preparations  known  as  beta- 
naphthol  and  hydronaphthol  were  employed,  and  the  author  considers  that 
the  effects  are  therapeutically  the  same.  Good  results  were  obtained  in  the 
dry  and  scaly  forms  of  eczema,  especially  in  eczema  of  the  scalp.  In  scabies 
the  author  is  able  to  corroborate  the  favorable  reports  of  Kaposi  and  Van 
Harlingen.  It  acted  well  also  in  pruritus,  pityriasis  capitis,  pediculosis  capitis, 
tinea  tonsurans,  and  alopecia.  In  two  cases  of  alopecia  areata  its  favorable 
effect  was  noticeable;  in  one  case  the  naphthol  crystals  were  rubbed  into  the 
patch,  in  the  other  the  remedy  was  applied  as  a  ten  per  cent,  ointment.  In 
other  affections  of  the  skin  than  those  above  named,  naphthol  showed  no 
special  influence.  The  drug  was  employed  usually  in  an  ointment  with 
vaseline,  lard,  or  lard  and  lanolin  in  the  strength  of  five  to  sixty  grains  to  the 
ounce.  In  collodion  it  acts  well  in  psoriasis,  trichophytosis,  etc.  It  may  also 
be  applied,  when  indicated,  in  powder  with  starch,  Fuller's  earth,  and  similar 
substances.  In  regard  to  the  possibility  of  danger  from  absorption,  the  author 
concludes,  from  his  experience,  that  if  a  pure  article  is  used  no  bad  effects 
will  occur. 


DERMATOLOGY. 


597 


ICHTHYOL  AND  KESORCIN :    A  CLINICAL  STUDY  OF  THEIR  EFFECTS. 

Jackson  contributes  [Journal  of  Cutaneous  and  Genito-  Urinary  Diseases, 
June  and  July,  1887)  his  experience  in  the  use  of  these  two  remedies.  Ich- 
thyol  (ammonio-sulphate)  was  employed  and  its  effects  followed  up  in  3  cases 
of  rosacea,  8  cases  of  eczema,  6  cases  of  acne,  1  case  of  sycosis,  and  3  cases  of 
ulcers.  In  rosacea,  in  2  cases  the  effect  was  negative ;  in  the  third  case  the 
disease  was  aggravated.  Of  the  eczema  cases,  4  were  made  worse,  2  were 
uninfluenced,  1  greatly  benefited,  and  1  temporarily  improved.  (In  these  last 
cases,  the  ichthyol  was  prescribed  in  Lassar's  paste.)  Of  the  acne  patients,  1 
was  cured  (bromide  of  arsenic  was  given  by  the  mouth),  2  made  worse,  1  tem- 
porarily benefited,  1  improved,  and  in  1  no  effect.  In  the  case  of  sycosis,  the 
disease  was  aggravated,  and  the  same  may  be  said  in  regard  to  the  3  cases  of 
ulcers  in  which  it  was  used.  In  the  above  cases  the  remedy  was  prescribed 
externally,  in  ointment,  with  vaselin  or  lard,  in  strength  varying  from  three 
to  thirty  per  cent. — the  weaker  strength  being  used  in  the  eczema  cases.  In 
some  cases,  also,  the  remedy  was  prescribed  by  the  mouth  in  addition  to  its 
use  externally.  The  author  passes  the  following  judgment:  Ichthyol  is  an 
unreliable  preparation  when  used  alone;  in  some  cases  it  is  of  apparent  benefit 
when  exhibited  as  an  adjuvant,  but  it  is  not  so  good  as  many  other  old  and 
well-approved  remedies. 

In  the  use  of  resorcin  the  writer  was  able  to  follow  out  its  effects  in  6  cases 
of  eczema,  3  of  epithelioma,  3  of  scrofuloderma,  in  1  of  lupus  erythematosus, 
1  of  lupus  vulgaris,  and  1  of  psoriasis.  In  eczema  it  was  prescribed  in 
ointment  and  glycerine,  two  to  twelve  per  cent,  strength;  1  case  was  cured,  2 
improved,  and  3  aggravated.  In  epithelioma,  in  five  to  fifty  per  cent,  oint- 
ment, all  (3)  the  cases  were  improved,  2  healing  completely,  although  later 
one  of  these  showed  a  return  at  the  edge  of  the  patch.  In  the  3  cases  of 
scrofuloderma,  in  ten  to  twenty  per  cent,  strength,  improvement  was  noted, 
in  one  a  cure  taking  place;  in  these  cases  arsenic  and  iron  were  taken  by  the 
mouth.  In  the  case  of  lupus  erythematosus,  under  the  use  of  a  twenty  per 
cent,  resorcin  ointment,  the  disease  rapidly  improved  ;  phosphorus  was  given 
internally.  In  the  case  of  lupus  vulgaris  (non-ulcerating),  constant  improve- 
ment was  noted.  In  the  patient  with  psoriasis,  the  first  effect  was  favorable, 
but  later  the  remedy  exerted  no  influence.  The  writer  summarizes  his  expe- 
rience with  resorcin  as  follows :  Eesorcin  is  an  irritating  substance  for  use  in 
eczema,  though  at  times  it  may  prove  very  efficient  in  chronic  cases  where 
active  stimulation  is  indicated.  It  exerts  a  powerful  absorptive  effect  on  new 
cell  infiltrations.  It  is  a  useful  addition  to  our  list  of  remedies  for  the  treat- 
ment of  epitheliomatous  lesions  where  surgical  procedures  are  contraindicated 
from  any  cause. 

Herpes  Digitalis. 

Under  this  name,  Blaschko  describes  (Deutsche  medicinuche  Wochenschr%ftt 
No.  27,  1887)  a  case  of  a  peculiar  recurrent  herpetic  eruption  occurring  on 
the  index-finger  of  the  right  hand.  The  eruption  was  confined  to  this  part, 
and  consisted  of  grouped  vesicles  upon  a  slightly  inflamed  base.  A  tow  days 
before  an  outbreak  there  is  more  or  less  neuralgic  pain  in  the  affected  finger 


598 


PROGRESS  OF   MEDICAL  SCIENCE. 


and  back  of  the  hand.  The  vesicles  are  deep-seated,  and  form  elevations  the 
size  of  a  split  pea.  There  is  at  first  slight  burning,  and,  later,  increasing 
itchiness  is  a  noticeable  symptom.  There  is  no  tendency  to  rupture,  the  thick 
unyielding  wall  of  the  lesions  preventing  this  termination ;  nor  is  there,  as  a 
rule,  any  tendency  to  spontaneous  involution.  If  the  lesions  are  not  soon 
punctured  and  emptied,  a  lymphangitis,  extending  up  the  arm,  with  painful 
enlargement  of  the  axillary  glands,  results.  The  contents  of  the  lesions  are 
usually  clear,  becoming  cloudy  if  of  long  duration.  This  process  has  recurred 
for  the  past  two  years,  at  first  three  or  four  months  intervening,  but  later  at 
intervals  of  six  or  eight  weeks.  The  number  of  lesions  present  in  the  different 
attacks  has  varied  from  two  to  fifteen.  The  duration  of  an  attack  depends, 
to  a  great  extent,  upon  the  number  of  vesicles,  averaging  about  two  weeks. 
There  was  no  scarring.  The  writer  regards  the  disease  as  probably  belonging 
to  the  trophoneuroses. 

A  Case  of  Chronic  Dysidrosis  of  the  Face. 

Rosenthal  reports  {Deutsche  medicinische  Wochenschrift,  No.  20,  1887)  a 
case  of  dysidrosis,  or  sudamen,  of  the  face  occurring  in  a  woman,  aged  fifty- 
four.  The  disease  has  lasted  nine  years,  becoming  worse  in  the  summer 
season.  The  lesions  appear  as  small,  solid  bodies  in  the  skin,  in  appear- 
ance not  unlike  milia.  On  examination,  however,  they  were  found  of  a 
vesicular  nature ;  the  contents  clear  and  of  an  acid  reaction.  A  few  vesicles 
contained  minute  blood  coagula,  due,  the  writer  considers,  to  external  trau- 
matic agency.  There  was  neither  scaling  nor  crusting.  Lesions  appeared 
to  last  almost  indefinitely ;  disappearing  always  by  absorption.  The  applica- 
tion of  a  one  to  two  per  cent,  alcoholic  solution  of  naphthol  was  found  useful. 

Eruption  from  Internal  Use  of  Arsenic. 

Dr.  Leontowitsch  [Monatshefte  fur  Prak.  Derm.,  No.  12,  1887)  reports  a 
case  of  eruption  from  the  internal  use  of  Fowler's  solution  occurring  in 
an  old  lady,  the  dose  being  a  small  one,  twice  daily,  administered  for  the 
relief  of  obstinate  chills  and  fever.  On  the  second  day,  severe  itching 
manifested  itself  on  the  neck  and  chest ;  on  the  third  day,  a  small  macular 
red  exanthem  appeared  upon  the  above-mentioned  regions,  the  skin  being 
slightly  swollen  and  the  seat  of  intolerable  itching.  By  the  fifth  day  it  had 
spread  over  the  abdomen.  Upon  discontinuing  the  remedy  the  cutaneous 
symptoms  disappeared  in  three  or  four  days,  but  were  reproduced  as  before 
on  taking  the  arsenic  a  second  time.  It  was  subsequently  shown  that  while 
the  patient  could  not  tolerate  either  arsenite  of  potassium  or  arsenious  acid 
with  bromide  of  potassium,  arsenite  of  quinine  caused  no  unpleasant  symp- 
toms.   An  idiosyncrasy  was  supposed  to  exist. 

On  the  Contagiousness  of  Tinea  Versicolor. 

Huble  [Annates  de  Derm,  et  de  Syph.,  No.  6,  1887)  has  recently  made  some 
researches  upon  tinea  versicolor,  its  transmissibility,  and  its  consequences  in 


DERMATOLOGY. 


599 


judiciary  medicine.  Kaposi  has  denied  its  contagion,  and  Hardy  has  stated 
that  it  is  but  slightly  contagious.  Huble  protests  against  these  views  and 
cites  nine  cases  of  contagion,  from  man  to  woman,  or  vice  versa.  He  mentions, 
moreover,  two  cases  of  mediate  contagion  through  the  means  of  flannel  under- 
shirts. The  author  gives  his  experience  with  inoculation.  In  the  first  series 
of  experiments  scales  scraped  from  a  patch  of  disease  were  simply  applied  to 
the  skin,  with  negative  results  at  the  end  of  thirty  days.  In  a  second  series 
of  experiments  the  skin  was  rubbed  until  red,  and  the  scales  were  applied  to 
the  surface  by  means  of  glycerine  and  plaster,  positive  results  appearing  at 
the  end  of  two  weeks.  In  a  third  series  in  one  spot  the  scales  were  removed 
with  a  lancet,  and  in  another  region  the  exfoliating  epidermic  scales  were 
simply  wiped  off,  and  the  tinea  scrapings  were  applied  by  means  of  glycerine 
and  gold-beater's  skin ;  in  both  places  evidences  of  the  disease  were  soon  (in 
a  few  weeks)  visible. 

A  Case  of  Pemphigus  Cured  by  Applications  of 
Oleate  of  Mercury. 

Crippe  (British  Medical  Journal,  January  29,  1887)  gives  the  notes  of  a 
case  of  an  extensive  pemphigoid  eruption  (Dermatitis  herpetiformis? — Eds.) 
of  several  months'  duration,  in  which  inunction  of  the  oleate  of  mercury 
seemed  to  bring  about  a  cure.  Blebs  were  present  in  large  numbers,  although 
at  times  the  eruption  was  of  a  multiform  type.  When  first  seen  small  doses 
of  arsenic  were  prescribed,  and  a  five  per  cent,  oleate  ointment  applied  to 
one  arm.  The  eruption  on  general  surface  remained  unchanged,  but  rapid 
improvement  was  noted  to  occur  on  the  part  to  which  the  oleate  had  been 
applied.  Later  the  same  ointment  was  gradually  prescribed  for  the  whole 
surface  and  with  the  same  favorable  result.  A  cure  was  effected  in  seven 
weeks. 

The  Pathology  of  Lichen  Kuber. 
Since  1880,  Kobner  (Berliner  Hinische  Wochenschrift,  Nos.  2(Tand  21,  1887) 
has  treated  fifty-two  cases  of  this  disease.  Of  this  number  only  two  were  of 
the  serious  type  described  by  Hebra.  The  author  recognizes,  as  do  most 
writers,  two  varieties  of  the  disease — lichen  ruber  acuminatus,  and  lichen 
ruber  planus — and  in  his  experience  the  latter  type  is  by  far  the  more  fre- 
\  quent.  The  writer  finds,  from  numerous  examinations,  that  this  disease  has 
primarily  its  beginning  in  dilatation  of  the  bloodvessels  and  perivascular 
cell-infiltration  in  the  upper  part  of  the  corium  in  the  papillae,  and  along  with 
this  is  noticed  rapid  growth  of  the  rete  ;  but  involvement  of  the  hair  follicles 
or  sweat-glands,  which  is  referred  to  by  most  writers,  was  found  to  be  incon- 
stant and  incidental.  Careful  examination  for  bacilli  gave  negative  results. 
The  author's  cases  tended  to  prove  the  neurotic  origin  of  the  disease. 
Arsenic  was  the  remedy  which  gave  good  results.  Unna's  ointment  was  found 
valueless. 


600 


PKOGRESS  OF   MEDICAL  SCIENCE. 


MIDWIFERY  AND  GYNECOLOGY. 


UNDER  THE  CHARGE  OF 

D.  Berry  Hart,  M.D.,  F.K.C.P.E., 

LECTURER  ON  MIDWIFERY  AND  DISEASES  OF  WOMEN,  SURGEON'S  HALL,  EDINBURGH,  ETC. 


Massage  in  Gynecology. 

Profenter  (Braumiiller,  Wien,  1887)  here  considers  the  effect  of  massage 
in  subacute  and  chronic  inflammatory  processes  in  the  female  pelvis.  In  a 
short  preface  Prof.  Schultze,  of  Jena,  states  that  he  has  tested  the  results  of 
the  method  and  found  them  good,  and  he  believes  "that  the  method  of  Brandt 
gives  valuable  results  in  stretching  and  slackening  old  parametric  exudations, 
as  well  as  restoring  fixation  in  prolapsus  uteri."  He  point  out,  also,  that  the 
treatment  requires  very  accurate  diagnosis  as  well  as  great  expenditure  of 
time.  In  the  introduction  Profenter  gives  the  history  of  the  application  of  the 
method.  It  is  due  to  a  Swede,  Brandt,  who  was  not  a  medical  man,  and  who, 
apart  from  professional  instruction,  gained  much  insight  into  pelvic  disorders. 
In  1847  he  treated  prolapsus  recti  in  a  soldier  by  rubbing  up,  as  it  were,  the 
sigmoid  flexure.  He  next  turned  his  attention  to  prolapsus  uteri,  and  cured, 
it  is  said,  three  cases  in  a  few  weeks.  The  method  was  then  extended  to 
retroflexed  and  fixed  uteri,  chronically  inflamed  ovaries,  and  chronic  cellulitic 
and  peritonitic  adhesions,  all  with  good  results.  Profenter  studied  Brandt's 
results  for  a  week,  found  them  good,  and  had  his  scepticism  removed.  Cases 
are  then  recorded.  Of  these  a  selection  is  appended.  It  must,  of  course,  be 
noted  that  the  massage  is  local  and  bimanual,  and  is  not  to  be  confounded 
with  the  general  massage  of  the  body  practised  in  Weir  Mitchell's  treatment. 

Case  1.  Chronic  parametritis  posterior,  chronic  ovaritis,  and  slight  cystitis. 
Oct.  23,  patient  has  pain  on  urination.  Bladder  washed  out  from  October 
24th  -to  November  10th :  rest  in  bed ;  alterative  tampons  also  tried. 

November  18th,  status  prcesens  as  follows :  Movement  of  the  uterus  to  the 
front  restricted ;  left  uterosacral  ligament  shortened,  thickened,  and  painful 
on  pressure ;  left  ovary  slightly  painful  on  pressure.  The  treatment  consisted 
in  systematic  stretching  of  the  shortened  ligament,  and  massage  of  the  left 
ovary.  On  December  4th,  the  uterus  had  its  fundus  to  the  left  of  the  median 
line,  and  movement,  even  to  the  neighborhood  of  the  symphysis,  was  painless. 

Case  12.  Chronic  parametritis  and  perimetritis.  Condition  under  narcosis : 
Marked  induration  of  the  broad  ligaments.  The  patient  complained  of  pain 
of  the  left  side  and  head ;  pain  on  micturition  and  defecation,  with  hysterical 
attacks  eight  days  before  menstruation.  By  massage  the  exudation  dis- 
appeared, and  the  uterus  and  ovaries  became  normal. 

Case  16  was  one  of  complete  prolapsus  uteri.  The  uterus  was  replaced  and 
anteflexed  according  to  Brandt's  method,  and  apparently  cured  in  a  month. 

[Massage  has  often  been  recommended  in  text-books,  especially  for  old  in- 
flammatory exudations.    Freund  has  also  recommended  it  in  such  cases,  and 


MIDWIFERY  AN  D  GYNECOLOGY. 


601 


it  is  undoubtedly  worthy  of  trial.  Schultze's  recommendation  is  of  high 
value  as  he  is  known  as  one  of  the  most  careful  observers  of  chronic  inflam- 
matory exudations,  and  his  work  on  their  relation  to  uterine  displacements  is 
of  the  greatest  value.  One  is  inclined  to  doubt  the  value  of  massage  in  pro- 
lapsus uteri  most] . 

Insanity  and  Oophorectomy. 

Leszynsky  (N.  Y.  Med.  Journ.,  June  25,  1887)  gives  an  account  of  two 
cases  in  which  oophorectomy  was  performed  for  insanity.  While  he  admits 
that  we  may  have  reflex  irritation  from  a  diseased  uterus  or  ovary,  he  points 
out  the  preponderance  of  psychical  causes  and  criticises  the  practice  of  oopho- 
rectomy in  the  insane,  alleging  that  "the  premature  and  indiscriminate 
removal  of  the  ovaries  in  cases  of  insanity  and  other  neuroses,  has  of  late 
become  so  frequent  and  flagrant  a  procedure  as  to  demand  an  emphatic  pro- 
test against  such  reprehensible  measures,  and  such  illegitimate  practice." 

Leszynsky  would  only  advise  oophorectomy  when  a  distinct  pathological 
condition  was  present,  and  had  a  preponderating  influence.  The  effect  of  sep- 
ticaemia in  mania  is  well  known.  Clouston,  in  his  Mental  Diseases  (London, 
1883)  says,  "I  believe  that  some  day  we  shall  hit  on  a  mode  of  producing  a 
local  inflammation  or  manageable  septic  blood  poisoning,  by  which  we  shall 
cut  short  and  cure  attacks  of  acute  mania."    (Op.  cit.,  p.  190.) 

On  Extraperitoneal  Extirpation  of  the  Uterus. 

Frank  (Arch./.  Gynak.,  Bd.  xxx.  Heft  1)  describes  a  series  of  extraordi- 
nary cases  where  he  performed  what  he  terms  extraperitoneal  extirpation  of 
the  uterus.  In  this  paper  he  does  not  detail  his  method  specially,  but  he  evi- 
dently in  certain  cases,  by  a  process  of  enucleation,  removes  the  greater  part 
of  the  uterine  substance  without  opening  the  peritoneal  cavity — i.  e.,  he  leaves 
the  peritoneum  intact.  The  summary  of  his  chief  cases  fully  justifies  the 
term  " tumor  operations,"  applied  by  Stratz  (Centr.fiir  Gynak.,  April  23, 1887). 
In  regard  to  risk  of  bleeding,  Frank  alleges  that  the  traction  on  the  uterus 
hinders  it.  The  suturing  of  the  peritoneal  folds  also  checks  it,  and,  if  neces- 
sary, ligatures  can  be  passed  up  as  far  as  the  Fallopian  tube  angle,  so  as  to 
control  the  ovarian  artery,  or  iron  solutions  can  be  applied. 

Frank  alleges  that  the  enthusiasm  for  total  extirpation  of  the  uterus  is 
greatly  diminished.  When  the  disease  has  advanced  so  far  as  to  affect  the 
body,  the  parametrium  is  sure  to  be  infiltrated  too.  He  advocates  his  opera- 
tions not  so  much  in  carcinoma  as  in  old  adherent  displacements,  pruritis 
uterinus,  and  adenomatous  degeneration. 

One  could  understand  this  operation  in  certain  cases  of  carcinoma  uteri. 
Marion  Sims,  in  one  of  his  last  papers,  records  a  case  of  carcinoma  uteri 
where  he  curetted  thoroughly,  so  that  he  could  have  inverted  the  thin  peri- 
toneal sac  of  the  uterus  and  ligatured  it.  He  did  not  do  so,  and  adds  that  he 
nearly  performed  a  brilliant  operation  (quoted  from  memory). 

On  a  Case  of  Spontaneous  Inversion  of  the  Uterus. 

Dr.  N.  T.  Brenis  [Edin.  Med.  Jour.,  July,  1887)  records  a  case  of  spon- 
taneous inversion  of  the  uterus,  following  the  expulsion  of  a  fibroid  polypus. 


602 


PROGRESS  OF   MEDICAL  SCIENCE. 


The  remarkable  feature  in  the  case  is  that,  after  attempts  at  manual  reinver- 
sion  had  failed,  rein  version  was  brought  about  by  the  repeated  use  of  the  hot 
douche.  He  considers  that  the  hot  water  acted  by  lessening  the  bulk  of  the 
organ,  and  bringing  about  contraction  of  the  longitudinal  fibres,  with  widen- 
ing of  the  constricting  ring. 

The  Application  of  Cocaine  in  Plastic  Gynecological  Operations. 

Kustner  (  Verh.  der  deutschen  gesellschaft  fur  GynaJc.,  Erst.  Koupres,  1886) 
considers  here  the  effects  of  cocaine  as  a  local  anaesthetic  in  some  of  the  plastic 
operations  in  gynecology.  Frankel  limits  the  use  of  cocaine  to  short  opera- 
tions, only  to  those  needing  merely  an  incision  or  scissor's  cut ;  while  Schramm 
would  employ  it  in  all  plastic  operations.  Kiistner  takes  an  intermediate 
position,  and  thinks  the  value  of  cocaine  can  best  be  estimated  by  trying  it  in 
painful  plastic  operations,  viz.,  those  at  the  posterior  commissure.  He  tried 
it,  therefore,  in  42  operations,  as  follows :  5  posterior  colporrhaphies,  31  partial 
plastic  operations  in  the  perineum,  4  total  plastic  operations  in  the  perineum, 
1  hymen  excision,  1  cyst  excision  on  the  left  side  of  the  vagina. 

The  parts  to  be  operated  on  were  first  disinfected,  and  then  repeatedly 
brushed  with  a  20  per  cent,  solution  until  the  mucous  membrane  was  some- 
what pale.  Poisoning  never  occurred.  The  results  were  as  follows :  In  8 
cases,  bad ;  the  patients  complained  of  great  pain  ;  in  23  cases  it  worked  well, 
and  in  10  there  was  complete  anaesthesia.  Kiistner  recommends  cocaine 
strongly  in  plastic  operations. 

[Cocaine  cannot  replace  general  anaesthesia,  as  we  must  remember  that  the 
patient  is  still  conscious  in  cocaine  operations.  What  most  women  in  this 
country  object  to  is  not  only  the  pain  but  the  exposure,  and  results  such  as 
Kiistner's  would  cause  mutiny  in  an  English  hospital.] 

The  Constitutional  Treatment  of  Puerperal  Sepsis. 

ErUNGrE  {Arch,  fiir  Gynah.,  Bd.  xxx.  Heft.  1)  here  gives  the  results  of  the 
form  of  treatment  he  recommends  in  puerperal  septicaemia.  This  consists  in 
the  administration  of  large  doses  of  alcohol,  the  use  of  tepid  baths,  and  abun- 
dant nourishment,  with  abundance  of  antipyretics.  He  holds  further,  that  as 
the  disease  goes  on  the  body  becomes  more  capable  of  resisting,  and  points 
out  that  while  local  treatment  can  limit  further  entrance  of  the  poison  we  can 
do  nothing  against  what  is  already  absorbed.  One  must,  therefore,  strengthen 
the  resisting  powers  of  the  organism.  The  alcohol  lessens  the  destruction  of 
albumen  in  the  body,  and  hinders  cardiac  failure,  while  the  baths  help  diges- 
tion, and  increase  appetite.  They  are  not  used  to  keep  down  temperature. 
The  temperature  of  the  water  should  be  72°-75°  F.,  and  the  bath  should  last 
for  five  to  ten  minutes.    Collapse  can  be  prevented  by  alcohol. 

Three  cases  are  narrated  with  one  death. 

[Eunge  uses  local  treatment,  too,  and  therefore  the  treatment  he  recommends 
is  what  most  men  would  employ  in  this  country,  with  the  exception  of  the 
tepid  baths,  which  seem  dangerous  and  troublesome,  unless  for  reduction  of 
high  temperature.  There  are  better  means  of  improving  the  appetite  and 
heart  than  this.] 


MIDWIFERY   AND  GYNECOLOGY. 


603 


On  Placenta  Previa. 

Bayer  (  Verhandlungen  der  deutschen  Gesellschaft  fur  Gynakologie)  advances 
a  new  theory  of  placenta  prsevia  cases,  in  order  to  harmonize  them  with  open- 
ing up  of  the  cervical  canal  during  the  later  months  of  pregnancy.  The  fol- 
lowing is  a  resume  of  his  views : 

He  first  states  Matthew  Duncan's  view  in  regard  to  the  hemorrhage  in 
placenta  prsevia.  According  to  Duncan,  the  lower  portion  of  the  uterus 
forms  in  advanced  pregnancy  a  part  of  half  a  sphere,  of  which  the  internal 
os  is  a  pole.  During  labor  this  segment  of  a  sphere  becomes  converted  into 
a  cylinder  with  consequent  dilatation  of  the  placental  site  and  separation  of 
the  placenta.  As  the  normally  placed  placenta  is  separated  (according  to 
Bayer  and  others)  by  uterine  retraction  which  arrests  bleeding  during  the 
separation,  the  bleeding  in  placenta  prsevia  is  caused  by  the  expansion  of  the 
lower  uterine  segment.  Of  course,  during  this  expansion  the  internal  os  also 
opens  up.  As  Duncan  holds  that  the  internal  os  only  opens  up  during  labor, 
he  logically  holds  any  bleeding  during  pregnancy  as  accidental. 

Since  Duncan's  paper  was  written,  the  development  of  the  lower  uterine 
segment  has  become  known  as  the  development  of  a  special  zone  between  the 
contracture  ring  and  Miiller's  ring.  The  development  of  the  lower  uterine 
segment  (from  the  cervical  canal)  explains,  according  to  this  writer,  the  bleed- 
ings in  placenta  prsevia  during  pregnancy. 

Bayer  then  considers  the  opinions  of  those  who  hold  that  the  lower  uterine 
segment  is  derived  from  the  uterus  by  stretching  and  thinning.  If  the  placenta 
is  inserted  over  the  os  internum,  it  must,  as  growth  of  the  segment  goes  on, 
either  be  separated  or  grow  with  it.  As  the  lower  uterine  segment  does  not 
take  part  in  uterine  retraction,  but  is,  as  it  were,  in  a  condition  of  paralysis; 
and  as,  if  uterine,  its  circulation  must  be  abundant,  fatal  hemorrhage  should 
take  place  during  placental  separation. 

Bayer  then  states  his  opinion  that  the  presence  of  the  placenta  in  the  lower 
uterine  segment  is  an  impossibility,  at  least  for  those  that  end  favorably.  In 
the  uteri  he  has  examined,  he  has  never  found  the  placental  site  below  an 
evident  contracture  ring  or  in  a  properly  formed  lower  uterine  segment. 

Bayer  alleges  that  the  idea  of  the  cervical  canal  opening  up  in  some  cases 
and  its  remaining  intact  in  others,  explains  the  clinical  features  of  placenta 
prsevia  as  well  as  the  anatomical  relations  he  has  observed. 

From  observations  of  about  20  cases,  he  asserts  that  defective  development 
of  the  supravaginal  portion  in  the  cervix  is  a  typical  occurrence  in  placenta 
prsevia,  that  in  the  worst  cases  the  internal  os  remains  intact  until  labor 
begins,  and  that  a  lower  uterine  segment  does  not,  therefore,  develop.  When 
the  placenta  dips  near  the  os  internum,  Bayer  believes  that  if  the  cervix  open 
up  to  form  the  lower  uterine  segment,  the  placenta  will  thus  be  carried  out, 
as  it  were,  from  the  dangerous  area  when  the  placenta  covers  the  os  internum. 
Bayer  holds  that  the  cervical  canal  may  not  open  up,  that  these  form  the 
cases  where  we  have  no  bleeding  until  the  full  time;  in  others,  he  holds  it  does 
open  up  and  we,  therefore,  have  bleedings  during  pregnancy  which  leave 
traces  in  the  placenta  and  membranes  there.  In  his  cases  these  changes  were 
found  in  the  placenta,  in  only  the  latter  class. 


604 


PKOGEESS  OF   MEDICAL  SCIENCE. 


A  Contribution  to  the  Anatomy  of  the  Post-partum  Uterus,  with 
Special  Keeerence  to  Placenta  Previa. 

Hart  [Edin.  Med.  Journ.,  July,  1887)  describes  the  relations  of  trie  anterior 
uterine  wall  in  a  woman  with  placenta  prsevia,  who  died  immediately  after 
delivery.  The  placenta  was  attached  to  the  anterior  uterine  wall,  and  it  was, 
therefore,  examined  by  the  microscopic  sections,  so  as  to  ascertain  the  various 
relations  of  peritoneum,  cervix,  etc.  He  found  the  cervical  canal  1J  inches 
long,  with  a  distinct  os  externum,  and  a  distinct  upper  limit  to  it.  Be- 
tween the  thick  retracted  wound  and  this  upper  limit  of  the  cervical  canal, 
was  a  thinner  portion,  with  peritoneum  separated,  and  with  placental  remains 
in  its  upper  half.    This  he  believes  to  be  the  lower  uterine  segment. 

He  therefore  asserts  that  this  preparation  shows  these  portions  of  the 
uterine  wall :  1.  A  thickened  retracted  portion,  with  peritoneum  adherent. 
2.  A  thinner  portion,  with  peritoneum  separated — lower  uterine  segment.  3. 
Cervical  canal.  He  believes  that  the  placenta  should  be  denned  as  praevia, 
when  attached  in  part  to  the  lower  uterine  segment,  and  that  it  is  separated 
during  labor  by  the  expansion  the  lower  uterine  segment  then  undergoes.  He 
holds  that  the  peritoneum  over  the  lower  uterine  segment  is  separated  in  the 
same  way,  and  that  the  diminution  in  area  occurring  about  the  contraction 
ring  can  only  separate  the  placenta.  He  therefore  alleges  that  he  has  demon- 
strated what  Bayer  terms  a  ''physiological  impossibility,"  viz.,  placenta  in 
lower  uterine  segment. 

Internal  Puerperal  Erysipelas. 

Winckel  (  Verh.  der  Deutschen  Oesellschaft  fur  Gynak.,  1886)  first  alludes  to 
a  previous  communication  given  by  him  at  Munich  on  puerperal  erysipelas, 
where  he  pointed  out  that  the  spread  of  erysipelas  took  place  through  the 
lymphatics  of  the  vagina,  uterus,  and  pelvis,  with  those  of  the  abdomen  and 
chest ;  that  in  all  lymphatic  forms  of  puerperal  fever  we  must  seek  for  chain 
micrococci  in  the  exudations,  in  the  pleura,  peritoneum,  and  in  the  joints. 
He  pointed  out  further,  the  frequency  of  pneumonia  in  puerperal  erysipelas, 
and  urged  that  we  have  in  it  a  poison  different  from  th?t  of  puerperal  fever. 
Gusserow  also  holds  the  same  opinion  in  relation  to  puerperal  fever  and  ery- 
sipelas. 

Winckel  now  gives  a  more  complete  research  on  this  interesting  subject. 
In  January,  1886,  a  patient  was  admitted  to  hospital  with  a  parametric  exu- 
dation, suppurating,  and  passing  through  the  ischiatic  notch.  Aspiration  of 
this  with  a  purified  Pravaz's  syringe  gave  pus  which  contained  the  erysipe- 
latous micrococci  of  Fehleisen.  A  pure  cultivation  of  them  was  obtained, 
and  erysipelas  conveyed  to  a  rabbit  by  it.  On  February  27, 1886,  a  primipara 
was  delivered  normally.  The  pulse,  however,  was  high  on  Winckel's  first 
visit  (120),  and  remained  above  100  for  the  next  two  days,  there  being  no  ele- 
vation of  temperature ;  on  the  evening  of  the  third  day  the  temperature  was 
100°  F. ;  next  morning,  102.5  °F.,  and  pulse  144.  Pressure  on  the  uterus  caused 
a  flow  of  badly  smelling  lochial  secretion.  On  the  posterior  commissure, 
fourchette,  and  the  inner  surface  of  the  left  labium  minus,  was  a  puerperal 


MIDWIFERY  AND  GYNECOLOGY. 


605 


ulcer.  During  the  night  there  were  great  pains  in  the  abdomen,  and  there 
developed  peritonitis,  with  erysipelas  on  the  nates.  Her  after-condition  was 
briefly  as  follows :  February  7th,  midday — pulse  128,  dicrotic ;  temperature 
102°  F. ;  respiration  42,  and  superficial.  Pains  felt  over  sacrum  and  epigas- 
trium. There  was  impairment  of  percussion  noted  over  the  bases  of  both 
lungs,  but  no  cardiac  murmurs.  Tymjmnites  was  very  great,  and  fundus  uteri 
two  finger-breadths  above  symphysis.  The  spleen  was  enlarged,  the  sacral 
regions  erysipelatous ;  no  oedema  or  other  change  in  the  legs.  Left  labium 
minus  swollen,  ulcerated ;  discharge  slight  and  mucopurulent.  Bladder  con- 
tained nearly  a  pint  of  clear  urine,  and  the  lips  of  the  cervix  uteri  were 
covered  with  croupous  exudation  passing  into  the  cervical  canal.  It  was 
impossible  to  make  out  any  parametric  exudation  separate  from  the  perito- 
nitic  one. 

.    Diagnosis. — Erysipelas  of  nates ;  vulvar  ulcers  ;  metrolymphangitis ;  diffuse 
fibrinous  peritonitis. 
Prognosis. — Bad. 

The  patient  went  on  from  bad  to  worse,  the  lung-mischief  increased,  with 
sickness  and  abdominal  pain.  Death  took  place  on  the  forenoon  of  February 
9th.  Before  the  body  had  cooled,  blood  was  aspirated  from  the  right  side  of 
the  heart  for  examination  as  to  microorganisms. 

On  post-mortem  examination  the  following  conditions  were  found :  Diph- 
theroid superficial  defect  at  vaginal  entrance ;  diphtheroid  endometritis  ; 
superficial  necrotic  metrolymphangitis;  purulent  salpingitis  of  the  outer 
tissue  of  the  right  tube ;  right-sided  ovaritis  ;  diffuse  purulent  peritonitis,  with 
considerable  mucopurulent  and  hemorrhagic  exudation ;  undoubted  cloudy 
swelling  of  the  sub-  and  retroperitoneal  connective  tissue  ;  double  pleurisy 
(beginning)  with  spread  to  diaphragm  and  purulent  affections  to  subpleural 
lymphatics  in  part. 

Marked  swelling  of  the  intestinal  tract  was  also  present,  with  marked 
anaemia  of  the  abdominal  organs. 

The  uterus  was  barely  the  size  of  a  man's  fist,  with  purulent  points  in  its 
walls.  The  uterine  cavity  was  the  size  of  a  hen's-egg,  and  contained  about  a 
teaspoonful  of  dirty  reddish-brown  fluid.  The  placental  site  had  been  on  the 
anterior  wall,  and  on  section  there,  spongy  and  purulent  foci  were  seen.  The 
pleural  sac  contained  a  little  cloudy,  grayish-red  fluid ;  anterior  mediastinum 
had  cedematous  swelling,  and  there  was  some  fluid  in  the  pericardium. 

The  blood  taken  shortly  after  death  from  the  right  side  of  the  heart  was 
found  to  contain  Fehleisen's  micrococci ;  these  were  cultivated,  and  when 
inoculated  into  a  rabbit's  ear  gave  it  erysipelas.  Erysipelatous  micrococci 
were  also  found  in  the  peritoneal  and  pleuritic  exudations.  They  were  also 
cultivated  from  spleen,  lungs,  uterus,  kidneys,  liver,  and  heart-muscle.  Micro- 
scopic examination  of  the  organs  gave  diplococci,  as  well  as  chain  cocci.  The 
kidneys  contained  many  micrococci  colonies. 

Inoculation  experiments  on  animals  gave  further  proofs,  but  rabbits,  guinea- 
pigs,  and  rats  showed  less  reaction  than  white  mice,  which,  after  inoculation, 
showed  severe  general  symptoms,  dying  in  periods  varying  from  six  hours 
to  seven  days.  Alcohol  was  found  to  inhibit  the  growth  of  the  micrococci, 
but  liquor  ferri  sesquichlorati  was  found  fatal  to  them. 


606 


PROGKESS  OF   MEDICAL  SCIENCE. 


The  following  is  a  summary  of  the  chief  points  in  this  most  valuable  paper: 

a.  Clinical  poin ts. 

1.  The  most  frequent  originating  points  in  five-sevenths  of  all  puerperal 
erysipelas  cases  are  the  genitals  and  nates — Hugenberger,  13  out  of  15 ; 
Gusserow,  7  in  14 ;  Winckel,  30  in  42. 

2.  Primiparse  are  affected  three  to  four  times  more  frequently  than 
multiparse. 

3.  Puerperse  with  vulvar  wounds  are  specially  predisposed: 

4.  Severe  operative  cases  are  affected  more  frequently  than  others. 

5.  The  children  of  erysipelatous  puerperse  remain  erysipelas-free. 

6.  The  greater  the  number  of  severe  puerperal  fever  cases,  the  greater  the 
number  of  erysipelatous  ones. 

b.  Bacteriological  points. 

7.  In  pus  from  a  parametritis  (Case  1)  and  in  all  the  organs  and  tissues  of 
a  fatal  case  of  puerperal  erysipelas,  were  the  characteristic  erysipelas  cocci 
found. 

8.  The  cultivations  gave  positive  results  agreeing  with  those  of  Fehleisen. 

c.  Points  made  out  by  experiments  on  animals. 

9.  Erysipelas  was  caused  in  different  animals  by  cultivations  of  erysipelas 
cocci,  obtained  from  the  tissues  of  the  puerperse  who  died. 

10.  By  injections  of  these  cultures  inflammatory  affections  were  obtained. 

11.  In  the  blood  and  organs  of  the  animals  so  infected  the  cocci  were 
found. 

12.  As  in  the  case  of  other  microorganisms,  different  animals  reacted  dif- 
ferently to  the  cocci.    The  most  easily  poisoned  are  white  mice. 

Winckel  uses  the  term  internal  puerperal  erysipelas.  For  puerperal  sepsis, 
he  suggests,  "  spaltpilzvergiftung,"  and  for  internal  puerperal  erysipelas, 
"  erysipelatose  spaltpilzvergiftung. 

[This  paper  is  an  important  one,  inasmuch  as  it  is  an  investigation  in  which 
Koch's  cultures  for  microorganisms  causing  a  disease,  are  fully  demonstrated. 
It  also  seems  to  follow  that  infection  takes  place  by  touch — hence  the  impor- 
tance of  purified  hands.] 

Cattle-Horn  Lacerations  of  the  Abdomen  and  Uterus 
In  Pregnant  Women. 

Harris  (American  Journal  of  Obstetrics,  July,  1887)  gives  here  the  known 
cases  of  cattle-horn  lacerations  of  the  pregnant  uterus  in  women.  The  re- 
markable fact  comes  out  that  the  results  as  to  the  mother's  life,  of  what  may 
be  termed  "  bovine  Csesarean  section,"  are  better  than  those  obtained  by  sur- 
geons, unless  in  quite  recent  times.  The  bad  results  obtained  by  tumor 
operators  in  Great  Britain  and  America  he  quite  rightly  attributes  to  delay  in 
operations  and  to  useless  and  hurtful  trials  to  deliver  by  craniotomy.  Thus 
the  record  of  Csesarean  operations  performed  by  medical  men  in  the  United 
States  for  the  last  seven  years  is  not  so  good  as  in  bovine  Csesarean  section, 
the  former  having  r.  mortality  of  nine  in  eleven  cases,  the  latter  of  four  in 
nine. 


MEDICAL  JURISPRUDENCE 


AND  TOXICOLOGY. 


607 


MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY- 


UNDER  THE  CHARGE  OF 

MATTHEW  HAY,  M.D., 

PROFESSOR  OF  MEDICAL  JURISPRUDENCE,  UNIVERSITY  OF  ABERDEEN. 


Rupture  op  the  Umbilical  Cord  at  Birth. 

P.  Budin  {Annal.  d'hyg.  pubL,  ser.  3,  t.  xvii.  pp.  534-540, 1887)  has  commu- 
nicated to  the  Societe  de  Medecine  legale  de  France,  a  paper  on  this  subject, 
in  which,  after  briefly  reviewing  a  few  cases  of  this  kind,  he  details  two  cases 
of  his  own,  which  happened  recently  within  the  Charite.  The  one  was  that 
of  a  woman,  aged  twenty-nine,  who  had  previously  borne  a  child,  and  who 
after  admission  to  the  Charite,  and  while  lying  in  bed,  expelled  a  mature  and 
living  foetus,  with  such  force  that  the  cord  was  ruptured  at  a  point  about  four 
inches  from  the  umbilicus.  The  child,  which  weighed  pounds,  sur- 
vived. The  cord  was  seventeen  inches  long.  The  other  case  was  that  of  a 
primipara,  aged  twenty-seven,  who  about  the  end  of  the  eighth  month  of 
pregnancy,  was  delivered  of  a  child,  which,  as  in  the  previous  case,  was  ex- 
pelled with  such  force  that  the  umbilical  cord  was  torn  across  near  to  the 
umbilicus,  although  the  woman  was  lying  horizontally  in  bed.  The  child 
weighed  5J  pounds,  and  the  length  of  the  cord  was  fifteen  inches.  The 
child  survived.  These  cases  are  interesting  to  the  medical  jurist  as  being 
extremely  rare. 

Detection  of  Spermatozoa  in  Spermatic  Stains. 

Ungar  (Viertelj.  f.  gerichtl.  Med.,  N.  F.,  Bd.  xlvii.  S.  316-327)  now  gives 
the  results  of  a  somewhat  elaborate  investigation  of  the  agents  most  suited 
for  staining  spermatozoa,  and  thus  revealing  their  presence.  He  describes 
several  methods  of  staining,  by  which  he  has  obtained  good  results.  He 
begins  by  placing  a  small  piece  of  the  cloth  stained  with  spermatic  fluid  in  a 
watch-glass  containing  distilled  water,  to  which  a  minute  quantity  of  hydro- 
chloric acid  has  been  added  (1  drop  to  1^  ozs.).  The  acid  prevents  the  sper- 
matozoa swelling  up  and  breaking.  Maceration  is  allowed  to  continue  for 
one  to  ten  hours,  depending  on  the  freshness  of  the  stain.  The  cloth  is  now 
removed  and  stripped,  and  the  strippings,  as  also  the  macerated  fluid,  placed 
in  a  thin  layer  on  a  number  of  cover-glasses.  The  fluid  is  then  dried  on 
the  cover-glasses  by  passing  them  three  times  quickly  through  a  flame. 
The  dried  residue  is  now  stained  by  placing  the  cover-glass  in  a  watch-glass 
containing  staining  fluid.  The  author  has  found  a  process  of  double-staining 
the  best.  For  this  purpose  he  employs  a  combination  of  cosine  and  haema- 
toxyline,  using  first  the  one  and  afterward  the  other.  The  eosine  solution 
consists  of  38  grains  of  eosine  dissolved  in  1  ounce  of  rectified  spirit  and  2* 
ounces  of  distilled  water.  The  cover-glass  is  allowed  to  swim  in  this  fluid  for 
one  hour.    It  is  then  removed  and  allowed  to  dry.    It  is  now  washed  with  a 


608 


PROGKESS  OF   MEDICAL  SCIENCE. 


mixture  of  one  part  of  alcohol  and  two  parts  of  water,  and  is  dipped  in  the 
haematoxyline  solution.  This  solution  is  made  according  to  the  Friedlander 
formula  or  to  Bohmer's  formula.  Friedlander's  is  haematoxyline  2  parts,  ab- 
solute alcohol  100  parts,  distilled  water  100  parts,  glycerine  100  parts,  alum  2 
parts.  The  solution  should  be  preserved  in  a  dark  place.  If  the  cover-glass 
with  dried  spermatozoa  is  allowed  to  remain  sufficiently  long  (a  few  minutes 
to  a  few  hours)  in  either  of  these  fluids,  a  characteristic  and  beautiful  double 
staining  is  finally  obtained.  While  the  hinder  part  of  the  head  of  the  sper- 
matozoa is  stained  dark-blue,  the  forepart  of  the  head,  the  middle  piece,  and 
the  tail  are  stained  deep  red,  as  are  all  other  parts  of  the  preparation,  except 
cell  nuclei,  which  are  blue.  The  addition  of  1  drop  of  acetic  acid  to  1  ounce 
of  the  haematoxyline  solution,  will  largely  prevent  overstaining  with  that 
reagent. 

Besides  this  combination  of  staining  reagents,  the  author  has  tried  others, 
of  which  he  gives  details,  but  none  is  so  perfect  as  that  described,  for  exam- 
ple, a  combination  of  carmine-alum  and  eosine,  or  of  vesuvine  and  eosine. 

Detection  of  Phosphorus  in  a  Body  Three  Months  after  Death. 

Poleck  (  Vierteljahrssckrift  fur  gerichtliche  Medicin,  N.  F.,  Bd.  xlvi.  S.  286- 
297,  and  Bd.  xlvii.  S.  41-55,  1887)  gives  the  details  of  a  case  of  phosphorus 
poisoning,  in  which  the  feature  of  chief  interest  was  the  detection  of  the 
poison  in  the  exhumed  corpse  three  months  after  death.  The  case  was  that 
of  a  man  who  had  been  poisoned  by  his  wife.  They  had  been  on  the  worst 
of  terms  for  some  time  previously.  After  a  midday  meal  of  flesh,  meal 
sauce,  etc.,  prepared  by  his  wife,  and  not  shared  as  usual  by  her,  the  husband 
was,  toward  evening,  suddenly  seized  with  a  violent  convulsion,  and  became 
almost  completely  unconscious.  After  an  hour  he  recovered.  Next  day  he 
was  very  ill,  suffering  from  occasional  convulsions,  violent  diarrhoea,  and 
involuntary  passage  of  urine  and  feces.  In  spite  of  this  no  doctor  was  called 
in.  The  man  died  on  the  fourth  day.  His  wife  was  at  once  suspected  by  the 
neighbors  of  having  poisoned  him,  but  as  the  doctor  who  was  asked  to  examine 
the  body,  certified,  from  an  external  examination,  that  the  man  had  died  of 
cerebral  apoplexy,  no  further  step  was  taken  at  the  time  by  the  criminal 
authorities,  and  the  body  was  buried.  But  as  suspicion  still  existed,  and 
became  gradually  stronger,  the  body  was  exhumed  three  months  after  death, 
and  a  complete  examination  was  made — the  pathological  by  Professor  Fried- 
berg,  and  the  chemical  by  Dr.  Poleck.  No  free  phosphorus  was  found  in  the 
body,  but  phosphorous  acid  was  met  with  in  the  alimentary  canal,  and  in  the 
tissues  generally.  As  phosphorous  acid  is  not  a  normal  constituent  of  the 
body,  Poleck  concludes  that  the  most  reasonable,  and  almost  the  sole  expla- 
nation of  its  existence,  is  that  it  was  due  to  the  partial  oxidation  of  phospho- 
rus. A  trace  of  arsenic  and  antimony  was  also  found.  This  was  of  interest, 
as  some  mice  poison  found  in  the  possession  of  the  accused  woman,  which 
consisted  largely  of  free  phosphorus,  contained  a  trace  of  arsenic  and  antimony. 

Toxicity  of  Acetylene. 

J.  Ogier  (Annal.  d'Hyg.  PubL,  ser.  3,  t.  xvii.  pp.  454-456,  3887),  read  a 
report  on  the  toxicity  of  acetylene,  at  a  recent  meeting  of  the  Societe  de 


PUBLIC  HEALTH. 


609 


Medecine  legale  de  France.  The  report  is  of  interest,  as  acetylene  is  a  gas 
which  is  largely  produced  in  the  imperfect  combustion  of  carbonaceous  ma- 
terial, and  is  an  important  constituent  of  coal  gas.  The  report  especially 
deals  with  the  experiments  of  M.  Brociner,  who  tested  the  action  of  acetylene 
on  blood,  and  caused  certain  animals  to  inhale  various  mixtures  of  acetylene 
gas  with  air  or  oxygen.  The  conclusions  arrived  at  are  the  following:  1. 
Blood  charged  with  acytelene  exhibits  no  characteristic  appearance  spectro- 
scopically.  2.  If  any  combination  is  formed  of  acetylene  and  haemoglobin, 
it  is  very  unstable.  3.  Acetylene  is  not  sensibly  toxic  by  itself,  and  in  this 
respect  resembles  other  members  of  the  same  chemical  group,  as  propylene. 


PUBLIC  HEALTH. 


UNDER  THE  CHARGE  OF 

SHIELEY  F.  MUEPHY,  M.E.C.S., 

LECTURER  ON  HYGIENE  AND  PUBLIC  IIEALTII,  ST.  MARY'S  HOSPITAL,  LONDON. 


Milk  Infection. 

In  the  January  number  of  the  present  year,  account  was  given  of  Dr.  Klein's 
investigation  into  the  relations  between  human  scarlatina  and  a  disease  of  the 
cow,  which  had  been  shown  by  Mr.  W.  H.  Power  to  be  its  cause.  Dr.  Klein 
has  since  continued  his  study  of  these  relations,  and  has  presented  to  the 
Eoyal  Society  a  paper  on  the  subject,  from  which  the  following  is  extracted. 
[Proceedings  of  the  Royal  Society,  vol.  xlii.) 

Dr.  Klein  had  previously  shown  that  certain  suspected  cows,  on  a  farm  at 
Hendon,  had  besides  a  skin  disease — consisting  of  ulcers  on  the  udder  and 
teats,  and  in  sores  and  scurvy  patches  and  loss  of  hair  in  different  parts  of  the 
skin — also  a  general  disease  of  the  viscera,  notably  the  lungs,  liver,  spleen,  and 
kidney,  which  resembled  the  disease  of  these  organs  in  acute  cases  of  human 
scarlatina.  He  had  further  shown  that  the  diseased  tissues  of  the  ulcers  on 
the  teats  and  udder,  produced  on  inoculation  into  the  skin  of  calves  a  similar 
local  disease,  which  in  its  incubation  and  general  anatomical  characters, 
proved  identical  with  the  ulceration  of  the  cow,  and  further,  that  from  the 
ulcers  of  the  cow  a  species  of  micrococcus  was  isolated  by  cultivation  in  arti- 
ficial nutritive  media,  which  microorganism  in  its  mode  of  growth  on  nutri- 
tive gelatine,  on  agar-agar  mixture,  on  blood  serum,  in  broth,  and  in  milk, 
proves  very  peculiar  and  different  from  other  species  of  micrococci  hitherto 
examined.  With  such  cultivation  of  the  micrococcus  he  had  produced  by 
subcutaneous  inoculation  in  calves  a  disease,  which  in  its  cutaneous  and  vis- 
ceral lesions  (lung,  liver,  spleen,  and  kidney)  bears  a  very  close  resemblance 
both  to  the  disease  which  was  observed  in  the  Hendon  cows,  as  well  as  to 
human  scarlatina. 

More  recently  in  examining  acute  cases  of  scarlatina,  Dr.  Klein  found  that 

NO.  CLXX XVIII.  —  OCTOBER,  1887.  39 


610 


PROGRESS  OF   MEDICAL  SCIENCE. 


there  is  present  in  the  blood  of  the  general  circulation  a  species  of  micro- 
coccus, which  on  cultivation  in  nutritive  gelatine,  agar-agar  mixture,  blood 
serum,  and  other  media,  proved  to  be  in  every  respect  identical  with  that 
obtained  from  the  Hendon  cows.  Out  of  eleven  acute  cases  of  scarlatina 
examined  in  this  direction,  four  yielded  positive  results,  three  were  acute 
cases  between  the  third  and  sixth  day  of  illness,  with  high  fever  and  tempe- 
rature, and  the  fourth  was  a  case  of  death  from  scarlatina  on  the  sixth  day. 
In  all  these  four  cases  several  drops  of  blood  were  used  after  the  customary 
methods  and  under  the  required  precautions  for  establishing  cultivations  in  a 
series  of  tubes  containing  sterilized  nutritive  gelatine,  and  generally  only  a 
very  small  number  of  these  tubes  revealed  after  an  incubation  of  several  days, 
one  or  two  colonies  of  the  micrococcus. 

Having  ascertained  the  identity  in  morphological  and  cultural  respects  of 
the  micrococcus  of  the  blood  of  human  scarlatina  with  the  organism  obtained 
from  the  Hendon  cows,  the  action  of  the  cultivations  of  both  these  sets  of 
micrococci  was  then  tested  on  animals,  and  the  results  compared.  It  was 
found  that  mice — wild  mice  better  than  tame  ones — on  inoculation,  as  well 
as  feeding,  became  affected  in  exactly  the  same  manner,  no  matter  whether 
the  one  set  of  cultivations  or  the  other  was  used.  The  great  majority  of  these 
animals  died  after  between  seven  or  twenty  days.  The  post-mortem  exami- 
nation revealed  great  congestion  of  the  lungs,  amounting  in  some  cases  to 
consolidation  of  portions  of  the  organ,  congestion  of  the  liver,  congestion  and 
swelling  of  the  spleen,  great  congestion  and  general  disease  of  the  cortical 
part  of  the  kidney.  From  the  blood  of  these  animals,  taken  directly  from 
the  heart,  cultivations  were  established  in  nutritive  gelatine,  and  hereby  the 
existence  of  the  same  species  of  micrococci  was  revealed ;  they  possessed  all 
those  special  characters  distinguishing  cultivations  of  the  micrococcus,  of  the 
Hendon  cows,  and  of  the  human  scarlatina. 

In  the  third  and  concluding  section  of  the  work,  cultivations  of  the  micro- 
coccus of  two  cases  of  human  scarlatina  were  used  for  infecting  calves  ;  two 
calves  were  inoculated  and  two  were  fed  from  each  set  of  cultivations ;  all 
eight  animals  developed  disease,  both  cutaneous  and  visceral,  identical  to  that 
produced  in  the  calves  that  had  been  last  year  infected  with  the  micrococcus 
from  the  Hendon  cows.  From  the  heart's  blood  of  calves  thus  infected  from 
human  scarlatina  the  same  micrococcus  was  recovered  by  cultivation,  possess- 
ing all  the  characters  shown  by  the  cultures  of  the  micrococcus  of  the  Hen- 
don cows  and  of  the  cases  of  human  scarlatina. 

Mr.  William  Brown,  F.R.C.S.,  Medical  Officer  of  Health  for  Carlisle, 
relates  in  The  Sanitary  Record  for  July,  1887,  an  account  of  an  outbreak  of 
typhoid  fever  in  Carlisle,  in  which  milk  was  the  vehicle  of  infection,  and 
where  typhoid  fever  in  the  inmates  of  the  dairy  was  associated  with  an  infec- 
tious fever  in  the  cow.  The  point  of  interest  in  the  paper  is  that  the  cases 
occurred  at  a  time  when  the  dairy  was  believed  to  be  free  from  infection,  but 
when  the  cows  were  suffering  from  a  febrile  malady.  Mr.  Dawson,  a  veterin- 
ary surgeon,  who  ha  J.  examined  the  animals,  stated  that  "the  diseases  from 
which  the  cows  suffered  were  all  more  or  less  of  a  febrile  character,  associated 
with  indigestion  and  occasionally  with  slight  cough ;  the  pulse  of  the  affected 


PUBLIC  HEALTH. 


611 


animals  was  increased  in  volume,  and  varied  from  60  to  80  beats  per  minute, 
the  normal  pulse  of  the  ox  being  from  40  to  45  per  minute-  The  nose  was 
hot  and  dry,  and  the  horns  were  alternately  hot  and  cold.  There  was  very 
marked  lumbar  tenderness,  which  was  very  characteristic  in  all  the  sick  ani- 
mals. There  was  slight  abdominal  breathing  from  febrile  condition.  Con- 
stipation was  generally  present,  but  not  serious.  There  were  only  two  cases 
of  purging ;  but  in  one  case  the  purging  was  very  great ;  the  motions  of  a 
frothy  character.  Some  of  the  animals  were  very  ill,  so  much  so  that  the 
dairyman  on  one  occasion  feared  that  one  of  them  would  die."  Mr.  Dawson 
had  some  cattle  presenting  similar  symptoms,  but  such  a  number  of  consecu- 
tive cases  of  this  nature  in  the  same  shed,  and  extending  over  such  a  length- 
ened period,  viz.,  four  years,  was  to  him  a  new  experience. 

Dr.  W.  J.  Simpson,  Medical  Officer  of  Health  for  Calcutta,  published  in 
the  Indian  Medical  Gazette  for  May,  1887,  an  investigation  into  an  outbreak  of 
cholera  which  occurred  on  board  a  sailing  vessel,  the  "  Ardenclutha,"  while 
lying  in  the  port  of  Calcutta.  It  was  discovered  that  ten  men  obtained  milk 
daily  from  a  native ;  of  these,  nine  were  attacked  with  illness,  four  had  cholera 
and  died,  and  five  had  severe  diarrhoea.  Only  one  man  who  drank  the  milk 
escaped,  and  he  had  only  a  very  small  quantity  ;  while  eight  men  who  used 
preserved  milk,  and  three  who  drank  none  at  all  were  not  affected.  The  cow 
from  which  the  milk  was  taken  was  in  good  health,  but  the  native  admitted 
that  his  milk  contained  twenty-five  per  cent,  of  water  drawn  from  a  tank  near 
his  house;  and  it  was  also  ascertained  that  some  of  his  neighbors  suffered  from 
cholera.  The  dejecta  from  an  imported  case  drained  into  the  tank,  and  the 
patient's  clothes  were  washed  in  it.  As  soon  as  the  milk  was  stopped  no  cases 
occurred  on  board  the  vessel,  though  one  person  living  near  the  tank  was 
attacked  two  days  later. 

Animal  Lymph  in  Berlin. 

In  Berlin,  in  the  Imperial  Vaccination  Institute,  during  the  latter  half  of 
1885  all  vaccinations  were  performed  with  animal  lymph,  two  months  being 
devoted  to  experiments  with  humanized  and  animal  lymph,  and  to  obtaining 
all  information  concerning  the  process  of  vaccination.  During  the  months 
August  to  December,  1885,  there  were  959  primary  vaccinations,  with  98  per 
cent,  personal,  and  68  per  cent,  insertion  success ;  and  738  revaccinations,  in 
which  the  personal  success  was  82  per  cent,  and  the  insertion  success  50  per 
cent.  In  addition,  450  tubes  were  sent  to  medical  men,  with  the  result  that 
of  511  primary  vaccinations,  the  success  was  99  per  cent,  personal  and  78 
per  cent,  insertion  success;  and  of  337  school  children  who  were  revaccinatcd, 
the  personal  success  was  97  per  cent.,  and  70  per  cent,  insertion  success. 

The  method  of  vaccinating  was  to  use  perfectly  fresh  lymph,  and  to  insert 
it  by  longitudinal  incisions  for  primary  vaccinations,  and  to  use  older  lymph 
in  scratches  for  re  vaccination. 

The  lymph  was  obtained  from  animals  in  the  Imperial  Veterinary  School ; 
there  is  a  large  place  for  special  animals,  which  is  of  an  even  temperature 
in  winter  and  summer. 

The  cost  in  Berlin  of  cultivating  animal  lymph  is  great ;  it  amounts  to  about 


612 


PROGKESS  OF  MEDICAL  SCIENCE. 


fifty  marks  (about  ten  dollars)  per  animal,  but  then  it  must  be  taken  into 
consideration  that  the  veterinary  school  is  outside  of  the  town,  and  the 
animals  must  be  brought  into  the  town  to  be  vaccinated,  and  taken  out  again. 

Retro- vaccination  was  practised  on  the  animal,  the  incisions  were  deep  all 
over  the  abdomen,  and  lymph  was  taken  five  times  after  twenty-four  hours. 
Only  the  upper  layer  of  lymph  was  free  from  blood,  but  the  blood  could 
always  be  removed  without  injury  to  the  lymph  by  the  use  of  distilled  water 
which  had  been  previously  boiled.  The  glycerine  emulsion  was  the  prepara- 
tion most  used,  because  it  was  found  that  decomposition  did  not  set  in  when- 
ever glycerine  was  mixed  with  the  lymph,  and  experiments  were  made  in 
which  lymph  was  kept  for  over  a  year,  and  success  attained  with  it  when 
employed  for  vaccination. 

Although  the  immediate  results  of  animal  vaccination  were  relatively 
favorable,  yet  in  the  end  it  led  to  a  diminished  insertion  success,  because,  on 
the  seventh  day,  when  lymph  is  to  be  taken  from  children  vaccinated  with 
calf  lymph,  the  vesicles  are  often  undeveloped  and  small,1  and  little  can  be 
obtained,  and  the  use  of  this  is  attended  by  less  satisfactory  results.  Dr. 
Schulz  comments  on  the  difficulty  of  taking  lymph  entirely  free  from  blood 
from  restless  children,  and  observes  that  the  method  adopted  in  Berlin  was  to 
mix  the  vaccine  obtained  from  each  child  with  glycerine,  put  it  into  tubes, 
which  were  then  stood  upright  until  the  blood  had  sunk  to  the  lower  end  of 
the  tube,  which  could  then  be  broken  off  and  sealed. 

Experiments  were  also,  during  1885  and  1886,  carried  on  at  the  Berlin  Vac- 
cination Station,  in  order  to  obtain,  if  possible,  pure  lymph  free  from  all  foreign 
bacteria.  Animal  lymph  contains  many  germs  which  are  not  necessary  for 
the  production  of  vesicles,  whereas  humanized  lymph  is  at  times  almost 
entirely  free  from  them  when  cultivated  on  meat  peptone  gelatine.  Different 
kinds  of  humanized  lymph,  therefore,  were  sown  in  small  quantities  of  gela- 
tine, and  wherever  colonies  developed  they  were  removed  from  the  gelatine, 
until  after  eight  days  only  those  portions  of  gelatine  remained  which  con- 
tained no  germs ;  this  was  then  used  for  vaccination,  but  in  a  very  small 
number  of  cases  was  there  any  result,  even  when  the  experiment  was  tried 
with  agar-agar  mixture,  and  it  was  probably  due  to  the  dilution  of  the  lymph 
in  the  cultivating  media. 

Dr.  Schulz,  therefore,  says  that  until  further  experiments  have  been  made, 
there  is  no  means  for  preventing  germs  from  entering  animal  lymph,  and  that 
all  that  can  be  relied  upon  is  cleanliness  in  vaccination,  and  in  taking  lymph 
either  from  animals  or  children. — Deutsche  Vierteljahrsschrift  f.  off.  Gesund- 
heitspflege,  Bd.  xix.  Heft  2,  1887. 

1  This  statement  is  not  in  accord  with  the  reports  of  the  Medical  Officer  of  the  Local  Government 
Board,  England,  on  "The  Animal  Vaccine  Establishment."  (Twelfth  Annual  Report  of  the  Local  Gov- 
ernment Board,  Supplement  containing  the  Report  of  the  Medical  Officer.) 


INDEX. 


ABDOMEN,  contusion  of,  with  rupture  of  intes- 
tine, 321 

Abdomen,  laparotomy  for  pistol-shot  wound  of,  562 
Abortion,  treatment  of,  282 
Abscess,  tubercular,  bacteria  and,  239 
Accommodation-strain,  relation  of,  to  glaucoma 

and  cataract,  572 
Acetanilid,  218 
Acetyline  toxicity  of,  608 

Acid,  carbonic,  union  of,  with  haemoglobin,  217 

Acid,  lactic,  uses  of,  in  dermatology,  278 

Actinomycosis  of  the  skin,  379 

Alcohol,  effects  of,  on  the  digestive  functions,  221 

Alkaloids,  veratrum,  actions  of,  523 

Amenorrhoea,  fatal  case  of,  277 

Aneurisms,  treatment  of,  255 

Angina  pectoris,  525 

Antifebrin,  218 

Antrum,  emphysema  of  the,  587 

Appendages,  uterine,  pathology  of  chronic  inflam- 
matory disease  of,  291 

Appendix  vermiformis,  laparotomy  for  perforation 
of,  561 

Arm,  base-ball  pitcher's,  566 

Arsenic,  eruption  from  internal  use  of,  598 

Arsenic  in  soil,  296 

Arteries,  pulsating,  of  the  pharynx,  274 
Arteritis,  syphilitic,  of  a  retinal  artery,  258 
Artery,  external  carotid,  ligature  of,  256 
Asthenia,  cardiac,  cocaine  in,  223 
Asthma,  dyspnoea  of,  393 
Asthma,  etiology  and  mechanism  of,  107 
Asthma,  German  and  French  treatment  of,  com- 
pared, 524 

Astigmatism,  relation  between  choroidal  crescent 
and,  569 

Atropia,  physiological  action  of,  on  the  iris,  259 
Attic,  tympanic,  chronic  purulent  inflammation 
of,  582 

DACTERIOLOGY,  69 

*^    Bile,  action  of  calomel  on,  527 

Bites,  leech,  cicatrices  of,  294 

Bladder,  operations  on,  550 

Bladder,  primary  sarcoma  of,  250 

Blood,  coagulation  of,  217 

Bloodletting,  value  of,  37 

Body,  restiform,  constitution  of  the,  211 

Brain,  abscess  in,  267,  268 


Brain,  treatment  of  suppuration  in,  271 
Breast,  amputation  of,  565 
Breast,  cancer  of,  241 
Breast,  female,  sarcoma  of,  17 
Bronchi,  topical  medication  of,  593 
Bronchitis,  dyspnoea  of,  393 

Broncho-pneumonia,  treatment  of,  in  children,  523 
Bursa  pharyngea,  212 

p^CUM,  hernia  of  the,  248 
^    Calomel  as  a  diuretic,  528 
Calomel,  action  of,  on  bile,  528 
Canal,  lachrymal,  inflammation  of,  263 
Castration  in  neuroses,  285 
Cataract,  artificially  produced,  261 
Cataract  extraction,  irrigation  of  anterior  chamber 
after,  261 

Cataract  extraction  without  iridectomy,  261 

Cataract,  glaucoma  and,  relation  of  accommodation- 
strain  to,  572 

Cataract,  senile,  spontaneous  absorption  of,  572 

Cavities,  pulmonary,  surgical  treatment  of,  244 

Charcot's  joint  disease,  550 

Cheyne,  bacteriology,  69 

Children,  hepatic  cirrhosis  in,  350 

"  Choked  disk,"  etiology  of,  264 

Chorea,  cardiac  relations  of,  371 

Chorea,  hereditary,  of  adults,  534 

Cirrhosis,  hepatic  in  children,  350 

Clarke,  action  of  sulphate  of  spartein,  363 

Cocaine,  use  of,  in  plastic  gynecological  operations, 
602 

Cocainomania,  294 

Coma,  diabetic,  pathogenesis  and  treatment  of,  535 

Concha,  sarcoma  of,  265 

Conjunctiva,  tuberculosis  of,  567 

Conjunctivitis,  catarrhal,  bacillus  of,  567 

Contusion-pneumonia,  245 

Cord,  umbilical,  rupture  of,  607 

Cornea,  transplantation  of,  262 

Cortex,  cerebral,  irritability  of  the  various  layers 
of  the,  216 

Cortex,  cerebral,  visual  centres  of,  216 

Crime,  statistics  of,  in  Europe,  291 

Curtis,  contusion  of  abdomen,  with  rupture  of  in- 
testine, 321 

Curvature,  corneal,  relation  of,  to  cranial  circum- 
ference, 568 
Cystotomy,  suprapubic,  563 


614 


INDEX. 


Cysts,  hydatid,  557 

Cysts,  synovial,  in  neighborhood  of  the  knee,  555 


DANA,  hereditary  tremor,  386 
Death,  diagnosis  of,  by  hanging,  293 
Death-point,  thermal,  of  pathogenic  organisms,  146 
Dermatitis  venenata,  279 
Diabetes,  albuminuria  in,  253 
Diabetes,  glycerine  and,  525j] 
Diabetes,  morphine  in,  233 
Diphtheria,  272 

Diphtheria,  early  tracheotomy  in,  273 
Diphtheria,  mould-fungi  as  causes  of,  584 
Diphtheria,  unusual  cutaneous  pigmentation  in, 
584 

Disease,  foot  and  mouth,  etiology  of,  301 
Dislocations,  fractures  and,  549 
Dislocations,  shoulder,  reduction  of,  243 
Disturbances,  visual,  from  cauterization  of  nasal 

passages,  573 
Dressings,  surgical,  555 
Duodenum,  position  of  the,  214 
Dupuytren's  contraction,  553 
Dyscrasia,  the  diabetic,  535 

Dysentery,  influence  of  meteorological  conditions 
on,  541 

Dysidrosis,  chronic,  of  face,  598 

IpAR,  foreign  bodies  in  the,  578; 
J    Ears,  boxing  the,  580 
Ectopion  vesicae,  249 

Elbow,  treatment  of  old  dislocations  of,  256 
Empyema,  treatment  of,  245,  253 
Endocarditis,  etiology  of,  539 
Erysipelas,  internal  puerperal,  604 
Erysipelas,  treatment  of,  241 
Eye,  gouty  affections  of  the,  260 
Eye,  influence  of  chronic  alcoholism  upon  the,  574 
Eye,  rabbit's,  transplantation  of,  into  the  human 
orbit,  260 

Eyeball,  report  on  500  enucleations  of,  574 
Eyelids,  spontaneous  closure  of,  after  death,  294 
Eyes,  injuries  of,  by  dynamite,  567 


T7EKMENTS,  digestive,  in  normal  and  patho- 

logical  urine,  235 
Eerment,  "starch-converting,"  in  human  urine, 

233 

Eever,  enteric,  epidemic  of,  302 
Fever  mountain,  226 
Fever,  scarlet,  contagion  of,  528 
Fingers,  relative  length  of,  and  toes,  215 
Fissure,  anal,  treatment  of,  564 
Flexure,  sigmoid,  position  of  the,  214 
Footprints,  medico-legal  study  of,  292 
Forceps,  obstetric,  ocular  Injuries  caused  by,  263 
Formiates,  disposal  of  the,  in  the  organism,  223 
Fractures  and  dislocations,  549 
Fraser,  dyspnoea  of  asthma  and  bronchitis,  393 
uruncle,  etiology  of,  595 


n  ALL-BLADDER,  operations  on,  553 


Or 


Gangrene,  diabetic,  amputation  in,  243 


Gastrotomy,  283 

Gland,  thyroid,  carcinoma  of,  594 

Glasgow,  etiology  and  mechanism  of  asthma,  107 

Glaucoma,  569,  570,  571,  572 

Glycerine  and  diabetes,  525 

Goitre,  exophthalmic,  imperfect  convergence  in, 
258 

Gonorrhoea,  injection  for,  521 

Gross,  6arcoma  of  the  female  breast,  17 

Gummata,  precocious,  53 


TT2EM0GL0BIN,  union  of  carbonic  acid  with,  217 


il 


Haematocele,  periuterine,  287 


Haematoma,  inter-meningeal,  treatment  of,  560 
Halsted,  circular  suture  of  intestine,  436 
"Hammer-toe,"  554 
Hanging,  diagnosis  of  death  by,  293 
Headache,  congestive,  treatment  of,  586 
Headache,  neuralgic,  415 

Heart,  general  pathology  of  diseases  of  the,  230 
Heart,  valvular  diseases  of  the,  229 
Hemeralopia,  epidemic,  573 
Hemiplegia  in  children,  530 
Hemorrhage,  middle  meningeal,  559 
Hemorrhoids,  treatment  of,  247,  564 
Hernia,  umbilical,  treatment  of,  282 
Herpes  digitalis,  597 

Howard,  hepatic  cirrhosis  in  children,  350 
Hydrophobia,  240,  557 
Hydroquinone,  526 

Hymen,  biperforate,  medico-legal  significance  of, 
293 

Hyoscine,  effects  of,  521 
Hypnotism,  522 


TCHTHYOL,  275,  597 
*-   Impetigo,  etiology  of,  595 
Impetigo  herpetiformis,  277 
Injections,  antiseptic  hypodermatic,  219 
Injury,  ocular,  by  lightning,  568 
Insanity,  dual,  analogy  between,  and  dual  suicide, 
295 

Insanity,  oophorectomy  and,  601 
Intestine,  circular  suture  of,  436 
Intestine,  rupture  of,  contusion  of  abdomen  and, 
321 

Intussusception,  treatment  of,  549 

Iodide  of  potassium,  effects  of,  on  assimilation  of 

nitrogenous  materials,  221 
Iodoform,  iodol  and,  225 
Iodol,  225,  240,  266 
Irido-cyclitis  tuberculosa,  568 
Iris,  physiological  action  of  atropia  on  the,  259 


JAW,  lower,  subluxation  of  the,  243 
Jaws,  diseases  of,  553 
Joint  disease,  Charcot's,  560 
Junction,  ileo-colic,  position  of  the,  214 


INDEX. 


615 


KIDNEY,  malignant  degeneration  of,  in  infancy, 
461 

Kidneys,  operations  on,  550 

Kinnicutt,  atrophy  of  gastric  tubules,  419 

Knee,  excision  of  the,  242 

Knee-joint,  internal  derangements  of  the,  242 

T  APAROTOMY,  254,  562 

Laryngectomy,  274,  592 
Larynx,  cysts  of,  590 
Larynx,  excision  of,  559 
Larynx,  intubation  of,  272,  591,  592 
Larynx,  lupus  of,  588 
Larynx,  oedema  of,  587 
Larynx,  tuberculosis  of,  588 
Leprosy  and  vaccination,  596 
Lichen  ruber,  pathology  of,  599 
Literature,  recent  surgical,  236,  545 
Lithotomy,  249,  250 
Liver,  functional  diseases  of  the,  542 
Lovett,  results  in  327  cases  of  tracheotomy,  160, 
476 

Lumbricales,  nervous  supply  of  the,  517 
Lungs,  surgical  treatment  of  affections  of,  245 
Lymph,  animal,  in  Berlin,  611 

M  ACDOUGALL,  value  of  bloodletting,  37 

Macewen,  the  pupil  in  its  semeiological  as- 
pects, 123 
Massage  in  gynecology,  600 
Massotherapy,  522 
Mastoid  operations,  577 
Measurements,  laryngeal,  275 
Membrane,  nasal  mucous,  cyst  of  the,  273 
Membrana  tympani,  management  of  perforation 
of,  265 

Meningitis,  infectious  cerebro-spinal,  225 

Mercurialism  in  lying-in  women,  284 

Mercury,  hypodermatic  injection  of  the  insoluble 

salts  of,  222 
Mesentery,  lipoma  of  the,  246 
Methylal,  527 
Micrococcus,  a  new,  240 

Middleton,  subcutaneous  nodules  in  hands  of  rheu- 

mati  patient,  433 
Milk,  infectious,  600 
Mitchell,  neuralgic  headache,  415 
Molluscum  contagiosum,  two  epidemics  of,  27S 
Morphine  in  diabetes,  233 

Munro,  results  in  327  cases  of  tracheotomy,  160, 
476 

Mycosis  fungoides,  556 
Mydriasis,  a  new  cause  of,  261 
Mydriatics,  influence  of,  upon  intraocular  pressure, 
571 

Myopia  in  the  schools  of  Stockholm,  260 
Myositis,  parenchymatous,  536 
Myotics,  influence  of,  upon  intraocular  pressure, 
571 


[  Nerves,  injuries  of,  456 

i  Nerves,  pneumogastric  and  recurrent  laryngeal, 

aneurismal  pressure  on,  593 
Neuritis,  peripheral,  227 
I  Neuroses,  castration  in,  85 
!  Neuroses,  nasal  and  nosopharyngeal  reflex,  273 
}  Nodules,  subcutaneous,  in  hands  of  rheumatic 

patient,  433 
!  Nose,  lupus  of  the,  273 
j  Nystagmus,  miners',  574 


fHSOPHAGOTOMT,  556 


(Esophagus,  stricture  of,  246,  274 


I  Oophorectomy,  insanity  and,  601 
Ophthalmia  neonatorum,  264 
Ophthalmoplegia  externa  acuta,  257 
Organism,  correlation  of  the  secreta  and  excreta  of 
the,  234 

Organisms,  pathogenic,  thermal  death-point  of,  146 
Osier,  cardiac  relations  of  chorea,  371 
Ovaries,  removal  of  both  during  pregnancy,  283 
Ozaena,  585 

PACHYDERMIA  laryngis,  590 
Palate,  cleft,  554 
i  Paracentesis,  extreme  frequency  of  pulse  after,  538 

Paralyses,  ocular,  etiology  of,  566 
!  Paralysis,  general,  of  the  insane,  228 
Paralysis,  Landry's,  532 
Paralysis,  mercurial,  526 
Paralysis,  periodic,  531 

Paralysis,  progressive,  pupillary  immobility  in,  569 
'  Parotitis,  248 

Pemphigus,  treatment  of,  599 
[  Penis,  horny  growth  of,  564 
|  Pereirine,  chlorhydrate  of,  225 
;  Peritonitis,  etiology  of,  247 
!  Pharyngitis  sicca,  275 
,  Pharynx,  excision  of,  559 

Phosphorus,  detection  of,  in  a  body  three  months 
after  death,  608 

Pilocarpine  in  catarrh  of  tympanum,  221 

Placenta  pnevia,  603 

Pleura,  surgical  treatment  of  affections  of,  245 
Pleurisy,  sudden  death  in,  229 
Pleurotomy,  253 

Plexus,  sacral,  morphology  of,  212 

Poisoning,  arsenical,  pseudo-tabes  from,  228 

Poisoning,  sulphuric  acid,  295 

Polyp,  laryngeal,  removal  of,  590 
I  Polypi,  mucous,  in  right  antrum,  273 
,  Pressure,  intracardiac,  21C 

Prostate,  function  of  the,  250 
I  Prostatitis,  acute,  hot  water  in,  223 
|  Pruritus  hiemalis,  596 

"Pug-nose,"  correction  of,  565 

Pulse,  extreme  frequency  of,  after  paracentesis,  538 

Punch,  the  cutaneous,  279 

Pupil,  the,  in  its  semeiological  aspects,  123 


VAPHTHOL,  596 

Nerve,  fifth,  treatment  of  neuralgia  of,  223 
Nerve,  optic,  incision  of  swollen  sheath  of,  364 


pECTUM,  diseases  of  the,  556 

Reflex,  pathological  nasal,  586 
Resections  and  amputations,  549 


616 


INDEX. 


Resorcin,  597 
Reviews— 

American  Gynecological  Society  Transactions, 
511 

American  Ophthalmological  Society  Trans- 
actions, 199 

Ballet,  Inner  Speech,  195 

Berbez,  Hysteria  and  Traumatism,  513 

Berger,  Amputation  of  the  Upper  Extremity, 
202 

Burnett,  Astigmatism,  505 

Charcot,  Diseases  of  the  Nervous  System,  503 

Dimmer,  The  Ophthalmoscope,  513 

Earle,  Curability  of  Insanity,  189 

East,  Private  Treatment  of  the  Insane,  189 

Ewald,  Handbook  of  Therapeutics,  207 

Gross,  S.  D  ,  Autobiography  of,  479 

Harris,  Before  Trial,  203 

Hartmann,  Diseases  of  the  Ear,  206 

Hofmann,  Analysis  of  the  Urine,  209 

Mackenzie,  Hygiene  of  the  Vocal  Organs,  205 

Marsh,  Diseases  of  the  Joints,  183 

Mauthner,  Muscular  Paralysis  of  the  Eye,  210 

Meyer,  Diseases  of  the  Eye,  515 

Mitchell,  Venom  of  Poisonous  Serpents,  500 

Parvin,  Science  and  Art  of  Obstetrics,  171 

Boss,  Aphasia,  195 

Savage,  Insanity  and  Allied  Neuroses,  189 
Smith,  Abdominal  Surgery,  509 
Sneguireff,  Uterine  Hemorrhages,  493 
Symington,  Topographical  Anatomy  of  the 
Child,  515 

United  States  Geological  Survey  Bulletin,  197 
Wright,  Hip  Disease  in  Childhood,  208 
Ziegler,  Pathological  Anatomy,  507 

Rhinitis,  atrophic,  275,  584 

Rhythm,  gallop,  232 

OALOL,  224 

^   Salpingitis,  etiology,  pathology,  and  classifica- 
tion of,  290 

Sanitation,  defective,  a  cause  of  puerperal  disease, 
281 

Sarcoma  of  female  breast,  17 
Sarcoma,  large,  of  occipital  lobe,  252 
Sciatica,  massage  in,  223 
Section,  abdominal,  283,  548 
Sepsis,  puerperal,  treatment  of,  602 
Septum,  nasal,  fibro-sarcoma  of,  274 
Sewage,  treatment  of,  303 
Smallpox  hospitals,  influence  of,  300 
Snow-blindness,  259 
Solanio,  520 
Spartein,  224,  303 

Spermatozoa,  detection  of,  in  spermatic  stains,  607 
Splenectomy,  254,  5C2 
Stenocarpine,  519 

Sternberg,  thermal  deatr  -point  of  pathogenic  or- 
ganisms, 146 
Stomach,  closure  of  cardiac  orifice  of,  213 


Stomach,  percussion  limits  of,  540 
Stools,  white,  significance  of,  544 
Sulphides,  alkaline,  mode  of  action  of,  297 
Sulphuretted  nydrogen,  mode  of  action  of,  297 
Surgery,  renal,  251 
Sycosis,  etiology  of,  585 
Syphilis,  mercurial  injections  in,  554 
Syphilis,  preventive  treatment  of,  222 

rpABLE,  a  new  operating,  555 

Taylor,  malignant  degeneration  of  kidney  in 
infancy,  461 
Taylor,  precocious  gummata,  53 
Tinea  versicolor,  contagiousness  of,  598 
Tinnitus  aurium,  treatment  of,  266 
Toes,  relative  length  of  fingers  and,  215 
Tongue,  black,  274 
Trachea,  topical  medication  of,  593 
Tracheotomy,  early,  in  diphtheria,  273 
Tracheotomy,  results  in  327  cases  of,  160,  476 
Tremor,  hereditary,  386 
Tube,  Eustachian,  pharyngeal  orifice  of,  518 
Tuberculosis,  peritoneal,  286 
Tubules,  gastric,  atrophy  of,  419 
Tumor,  nasopharyngeal,  removal  of,  584 
Tumors,  552 

Tumors,  tuberculous,  of  nasal  mucous  membrane, 

585 

Tympanum,  treatment  of  catarrh  of,  221 
Typhoid,  sudoral  eruptions  as  a  prognostic  sign  in, 

528 

Tf  LEXINE,  524 

U    Urine,  cause  of  development  of  sulphuretted 

hydrogen  in,  555 
Urine,  diabetic,  reducing  substances  in,  236 
Urine,  normal,  serum-albumin  in,  236 
Urine,  test  for,  544 

Urine,  pathological  coloring  matters  in,  545 
Uterus,  cancer  of,  288 

Uterus,  cattle-horn  lacerations  of,  in  pregnant 

women,  606 
Uterus,  extraperitoneal  extirpation  of,  601 
Uterus,  post-partum  anatomy  of,  604 
Uterus,  puerperal,  complete  inversion  of,  281 
Uterus,  spontaneous  inversion  of,  601 

yACCINATION  in  Russia,  298 
'     Vaccination,  leprosy  and,  596 
Vein,  internal  jugular,  ligature  of,  565 
Vertigo,  nasal,  586 

Vesicle,  microorganisms  in  the  varicella,  227 
Vitreous,  substitutes  for,  after  evisceration,  260 

WRIST,  synovial  sheath  of  radial  extensors  of, 
517 

ROSTER,  chronic,  280 


New  York  Post-Graduate  Medical  School 
and  Hospital, 

224-230  East  20th  Street,  New  York  City. 


Incorporated  by  Special  Act  of  the  Legislature  of  the  State  of  New  York. 


FOR  PRACTITIONERS  OF  MEDICINE  EXCLUSIVELY. 


SIXTH  YEAR.     SESSIONS  OF  1887-88. 


FACULTY. 


WILLIAM  A.  HAMMOND,  M.D.,  Professor  of 
Diseases  of  the  Mind  and  Nervous  System,  and 
of  Medical  Electricity,  Surgeon-General  of  the 
U.  S.  Army  (retired  list). 

D.  B.  ST.  JOHN  EOOSA  M.D.,  LL.D.,  Professor 
of  Diseases  of  the  Eye  and  Ear,  Surgeon  to  the 
Manhattan  Eye  and  Ear  Hospital,  President  of 
the  Faculty. 

FREDERIC  R.  STURGIS,  M.D.,  Professor  of  Dis- 
eases of  the  Genito-Urinary  Organs,  and  of  Ven- 
ereal Diseases,  Surgeon  to  the  Charity  Hospital. 

THOMAS  E.  SATTERTHWAITE,  M.D.,  Professor 
of  Pathology  and  General  Medicine,  Pathologist 
to  the  Presbyterian  Hospital. 

CHARLES  L.  DANA,  M.D.,  Professor  of  Diseases 
of  the  Mind  and  Nervous  System  and  of  Medical 
Electricity,  Professor  of  Physiology  Woman's 
Medical  College,  Physician  to  Bellevue  Hospital. 

M.  JOSIAH  ROBERTS,  M.D.,  Professor  of  Ortho- 
paedic Surgery  and  Mechanical  Therapeutics, 
Visiting  Orthopaedic  Surgeon  to  the  Randall's 
Island  Hospitals. 

ANDREW  H.  SMITH,  M.D.,  Professor  of  Clinical 
Medicine  and  Therapeutics,  Attending  Physician 
to  the  Presbyterian  Hospital,  Consulting  Physi- 
cian to  the  Orthopaedic  Hospital. 

WILLIAM  OLIVER  MOOES,  M.D.,  Professor  of 
Diseases  of  the  Eye  and  Ear,  Professor  of  Dis- 
eases  of  the  Eye  and  Ear,  University  of  Vermont 
and  Woman's  Medical  College,  New  York. 

BACHE  McE.  EMMET,  M.D.,  Professor  of  Dis- 
eases of  Women,  Assistant  Surgeon  to  the  New 
York  State  Woman's  Hospital. 

EDWAED  KEESHNEE,  M.D.,  U.  S.  N.,  Professor  j 
of  Naval,  Military,  and  State  Hygiene. 

AMBEOSE  L.  EANNEY,  M  B,  Professor  of  the 
Anatomy  and  Physiology  of  the  Nervous  System, 
Professor  of  Diseases  of  the  Mind  and  the  Ner- 
vous System,  University  of  Vermont. 


WILLIAM  HENEY  POETEE,  M.D.,  Professor  of 
Clinical  Medicine  and  Pathology,  Curator  of  the 
Presbyterian  Hospital. 

GEOEGE  HENEY  FOX,  M.D.,  Professor  of  Dis- 
eases of  the  Skin,  Professor  of  Dermatology, 
College  of  Physicians  and  Surgeons,  New  York. 

STEPHEN  SMITH  BUET,  M.D.,  Professor  of 
Physical  Diagnosis,  Physician  to  the  Out-Door 
Department,  Bel levue  Hospital. 

SENECA  D.  POWELL,  M.D.,  Professor  of  Clinical 
Surgery,  Surgeon  to  St.  Elizabeth's  Hospital. 

C.  A.  VON  EAMDOHE,  M.D.,  Professor  of  Ob- 
stetrics, Physician  to  the  German  Poliklinik. 

HORACE  T.  HANKS,  M.D.,  Professor  of  Diseases 
of  Women,  Assistant  Surgeon  to  the  New  York 
State  Woman's  Hospital. 

LEWIS  S.  PILCHER,  M.D.,  Professor  of  Clinical 
Surgery. 

HENRY  J.  GAREIGUES,  M.D.,  Professor  of  Ob- 
stetrics, Surgeon  to  the  Maternity  and  German 
Hospitals. 

CLAEENCE  C.  EICE,  M.D.,  Professor  of  Diseases 
of  the  Throat  and  Nose,  Consulting  Surgeon  to 
the  Out-Door  Department,  Bellevue  Hospital. 

CHA.ELES  CAEEOLL  LEE,  M  D,  Professor  of 
Diseases  of  Women,  Surgeon  to  the  New  York 
State  Woman's  Hospital,  Consulting  Surgeon  to 
Charity  Hospital. 

GEAEME  M.  HAMMOND,  M.D.,  Professor  of  Dis- 
eases of  the  Mind  and  Nervous  System. 

J.  E.  NILSEN,  M.D.,  Professor  of  Diseases  of 
Women. 

GEOEGE  B.  FOWLEE,  M.D.,  Professor  of  Clini- 
cal Medicine  and  Medical  Chemistry,  Physician 
to  Bellevue  Hospital. 


This  School  was  founded  by  members  of  the  Post-Graduate  Faculty  of  the  University  of  the  City  of 
New  York,  and  was  the  first  institution  in  the  United  States  to  present  a  systematic  system  of  clinical 
instruction  for  graduates  in  medicine. 

The  teaching  is  practical  and  thorough.  The  school  is  not  a  mere  clinic,  although  all  the  lectures 
are  clinical,  but  it  is  a  place  of  instruction  in  which  the  practitioner,  by  actually  handling  the  cases 
under  the  guidance  of  the  Professors  and  Instructors,  may  learn  the  use  of  Instruments  for  examina- 
tion and  treatment,  and  observe  the  effects  of  remedies.  Its  facilities  are  unrivalled.  Each  hospital  to 
which  the  teachers  are  attached  forms  a  part  of  the  field  of  instruction.  The  general  schedule  is  so 
arranged  that  there  is  no  conflict  in  the  hours  of  attendance  of  the  Professors.  The  clinics  begin  at 
9  a.  m.  and  continue  until  9  p.  M.  ea^h  day  ;  and  the  Clinical  Society  of  the  School  meets  twice  a  month  on 
Saturday  evenings.  A  Dispensary  and  a  Hospital  form  a  part  of  the  School,  with  one  ward  exclusively 
for  infants,  which  has  been  lately  endowed  by  benevolent  ladies  of  New  York  City.  Dr.  Joseph 
O'Dwyer,  the  inventor  of  Intubation  of  the  Larynx,  gives  practical  instruction  to  classes  organized 
in  this  School,  and  only  here. 


X&B"  Sessions  continue  throughout  the  year.  Physicians  may  join  the  classes  at  any  time.  For 
Catalogue,  or  further  information,  address, 


CLARENCE  C.  RICE,  Secretary  of  the  Faculty. 
John  Humphreys,  Clerk.  226  East  20th  Street,  New  York  City. 


University  of  the  City  of  New  York. 

MEDICAL  DEPARTMENT. 

410  East  Twenty -Sixth  Street,  opposite  Bellevue  Hospital,  ~New   York  City. 


FORTY-SEVENTH   SESSION,  1887-88. 


FACULTY   OF  MEDICINE. 


REV.  JOHN  HALL,  D.D.,  LL.D.,  Chancellor  of 

the  University. 
REV.  HENRY  M.  McCRACKEN,   D.D.,  Yice- 

Chancellor. 

CHARLES  INSLEE  PARDEE,  M.D.,  Dean  of  the 
Faculty ;  Professor  of  Otology. 

J.  W.  S.  ARNOLD,  M.D.,  Professor  Emeritus  of 
Physiology  and  Histology. 

ALFRED  L.  LOOMIS,  M.D.,  LL.D.,  Professor  of 
Pathology  and  Practice  of  Medicine  ;  Physician 
to  Bellevue  Hospital. 

WILLIAM  H.  THOMSON,  M.D.,  LL.D.,  Pro- 
fessor of  Materia  Medica  and  Therapeutics ; 
Diseases  of  the  Nervous  System  ;  Physician  to 
Bellevue  Hospital. 

J.  WILLISTON  WEIGHT,  M.D.,  Professor  of 
Surgery  ;  Surgeon  to  Bellevue  Hospital. 

WM.  MECKLENBURG  POLK,  M  D.,  Professor 
of  Obstetrics  and  Diseases  of  Women  and  Chil- 
dren; Physician  to  Bellevue  Hospital,  and  to 
Emergency  Lying-in  Hospital. 

LEWIS  A.  STIMSON,  M.D  ,  Professor  of  Anat- 
omy ;  Professor  of  Clinical  Surgery  ;  Surgeon  to 
Bellevne  and  Presbyterian  Hospitals. 

RUDOLPH  A  WITTHAUS,  M.D.,  Professor  of 
Chemistry  and  Physics. 

WM.  G.  THOMPSON,  M.D.,  Professor  of  Physi- 
ology. 

STEPHEN  SMITH,  M.D.,  Professor  of  Clinical 
Surgery  ;  Surgeon  to  Bellevue  Hospital. 

A.  E.  MACDONALD,  LL.D.,  M.D.,  Professor  of 
Medical  Jurisprudence  and  Psychological  Medi- 
cine ;  General  Superintendent  of  the  New  York 
City  Asylums  for  the  Insane. 


HERMANN  KNAPP,  M.D.,  Professor  of  Oph- 
thalmology ;  Surgeon  to  the  New  York  Ophthal- 
mic and  Aural  Institute. 

FANEUIL  D.  WEISSE,  M.D.,  Professor  of  Prac- 
tical and  Surgical  Anatomy  ;  Surgeon  to  Work- 
house Hospital,  B.  I 

HENRY  G.  PIFFARD,  M.D.,  Clinical  Professor 
of  Dermatology  ;  Consulting  Surgeon  to  Charity 
Hospital. 

F.  R.  S.  DRAKE,  M.D.,  Clinical  Professor  of 
Medicine  ;  Physician  to  Bellevue  Hospital. 

JOSEPH  E.  WINTERS,  M.D.,  Clinical  Professor 
of  Diseases  of  Children. 

PRINCE  A.  MORROW,  M.D.,  Clinical  Professor 
of  Venereal  Diseases ;  Surgeon  to  Charity  Hos- 
pital. 

WILLIAM  C.  JARVIS,  M  D.,  Clinical  Professor 
of  Laryngology. 

LAURENCE  JOHNSON,  M.D.,  Professor  of  Medi- 
cal Botany;  Visiting  Physician  to  Randall's 
Island  Hospital. 

WESLEY  M.  CARPENTER,  M.D  ,  Clinical  Pro- 
fessor of  Medicine. 

HARRY  P.  LOOMIS,  M.D.,  Adjunct  Professor  of 
Pathology,  and  Director  of  the  Pathological 
Laboratory. 


.  C.  BLAISDELL, 
Anatomy. 


M.D.,    Demonstrator  of 


MAURICE  N.  MILLER,  M.D.,  Director  of  the 
7    Histological  Laboratory. 


The  Preliminary  Session  will  begin  on  Wednesday,  September  21,  1887,  and  end  October  4,  1887. 
It  will  be  conducted  on  the  same  plan  as  the  Regular  Winter  Session. 

The  Regular  Winter  Session  will  begin  October  5,  1887,  and  end  about  March,  1888.  The  plan 
of  Instruction  consists  of  Didactic  and  Clinical  Lectures,  recitations,  and  laboratory  work  in  all  subjects 
in  which  it  is  practicable. 

Laboratories  and  Section  Teaching.— The  complete  remodelling  of  the  College  building,  and  the 
addition  of  the  new  "Loomis  Laboratory"  adjoining,  will  be  completed  for  the  opening  of  the  session 
of  1887-88.  They  will  afford  greatly  increased  laboratory  accommodations  in  the  departments  of 
Biology,  Pathology,  Physiology,  Chemistry,  and  Physics.  A  new  amphitheatre  and  a  new  lecture  room 
have  been  provided,  as  well  as  adequate  facilities  for  Section  teaching,  in  which  the  material  from  the 
College  Dispensary  will  be  utilized. 

Two  to  five  Didactic  Lectures  and  two  or  more  Clinical  Lectures  will  be  given  each  day  by  members 
of  the  Faculty.  In  addition  to  the  ordinary  clinics,  special  clinical  instruction,  without  additional  expense, 
will  be  given  to  the  candidates  for  graduation  during  the  latter  part  of  the  Regular  Session.  For  this 
purpose  the  candidates  will  be  divided  into  sections  of  twenty -five  members  each.  All  who  desire  to 
avail  themselves  of  this  valuable  privilege  must  give  in  their  names  to  the  Dean  during  the  first  week. 
At  these  special  clinics  students  will  have  excellent  opportunities  to  make  and  verify  diagnoses,  and 
watch  the  effects  of  treatment.  They  will  be  held  in  the  Wards  of  the  Hospitals  and  at  the  Public  and 
College  Dispensaries. 

Each  of  the  seven  Professors  of  the  Regular  Faculty,  or  his  assistant,  will  conduct  a  recitation  on  his 
subject  one  evening  each  week.  Students  are  thus  enabled  to  make  up  for  lost  lectures  and  prepare 
themselves  properly  for  their  final  examinations  without  additional  expense. 

The  Spring  Session  will  begin  about  the  middle  of  March  and  end  the  last  week  in  May.  The  daily 
Clinics  and  Special  Practical  Courses  will  be  the  same  as  in  the  Winter  Session,  and  there  will  be  Lectures 
on  Special  Subjects  by  Members  of  the  Faculty. 

It  is  supplementary  to  the  Regular  Winter  Session.  Nine  months  of  continued  instruction  are  thus 
secured  to  all  students  of  the  University  who  desire  a  thorough  course. 


FEES. 

For  course  of  Lectures  

Matriculation  

Demonstrator's  Fee,  including  material  for  dissection 
Final  Examination  Fee  


§140.00 
5.00 
10.00 
30.00 


For  further  particulars  and  circulars  address  the  Dean, 

PROF.  CHAS.  INSLEE  PARDEE,  M.D., 

University  Medical  College,  410  East  26th  St.,  New  York  City. 


\ 


J 


as 


LEA  BROTHERS  &  CO.'S 

(Late  HENRY  C.  LEAS  SOU  4  CO.) 

CLASSIFIED  CATALOGUE 


w  MEDICAL  AND  SURGICAL 

>>  PUBLICATIONS. 


rt   

^  In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following  pages* 

the  publishers  would  state  that  no  pains  are  spared  to  secure  a  continuance  of  the  confi- 
^  dence  earned  for  the  publications  of  the  house  by  their  careful  selection  and  accuracy  and 
q    finish  of  execution. 

gj  The  large  number  of  inquiries  received  from  the  profession  for  a  finer  class  of  bindings  than  is 

usually  placed  on  medical  books  has  induced  us  to  put  certain  of  our  standard  publications  in 
m  half  Russia;  and,  that  the  growing  taste  may  be  encouraged,  the  prices  have  been  fixed  at  so  small 
an  advance  over  the  cost  of  sheep  as  to  place  it  within  the  means  of  all  to  possess  a  library  that 

^    shall  have  attractions  as  well  for  the  eye  as  for  the  mind  of  the  reading  practitioner. 

O  The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 

^  throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works  not 
kept  in  stock.  Where  access  to  bookstores  is  not  convenient  books  will  be  sent  by  mail 
postpaid  on  receipt  of  the  price,  and  as  the  limit  of  mailable  weight  has  been  removed,  no 

CO  difficulty  will  be  experienced  in  obtaining  through  the  post-office  any  work  in  this  cata- 
logue.    No  risks,  however,  are  assumed  either  on  the  money  or  on  the  books,  and  no  pub- 

tLm  lications  but  our  own  are  supplied,  so  that  gentlemen  will  in  most  cases  find  it  more  con- 
venient  to  deal  with  the  nearest  bookseller. 

4-»  LEA  BEOTHEKS  A  CO 


Nos.  706  and  708  Sansom  St.,  Philadelphia,  October,  1887. 


=  PROSPECTUS  FDR  1BBB. 

te   

oj  The  Monthly  Publication  of 

O 

S  The  American  Journal  of  the  Medical  Sciences. 

C  To  be  issued  at  the  beginning  of  each  month.    Over  100  large  octavo  pages 

^%  of  reading  matter  in  each  number. 

CD   


Subscription  Price  Reduced  to  $4.00  per  annum. 
O   

rpHE  large  circle  of  readers  of  The  American  Journal  of  the  Medical  Sciences 
J_  wiH  learn  with  satisfaction  that,  with  the  coming  of  the  New  Year,  they  will  receive 
£  its  visits  monthly  instead  of  quarterly,  as  heretofore.  This  change  is  simply  a  further 
U>  development  of  that  spirit  which  has  caused  The  Journal,  during  two  generations,  to 
r5j*  be  always  the  leader  in  medical  thought,  divining  the  needs  of  the  profession,  and  shaping 
^  itself  for  their  adequate  supply.  The  period  thus  Air  spanned  by  the  life  of  The 
C  Journal  is,  par  excellence,  the  Augustan  Age  of  medicine.  Never  before  in  history  have 
05  the  brains  of  individual  men  been  so  heavily  taxed,  or  so  fertile  in  physical  benefit  to  the 
CD    human  race.    If  the  present  rate  of  progress  is  to  be  accelerated  or  even  maintained,  it 

can  only  be  by  means  of  increased  rapidity  in  the  interchange  of  thought,  and  by  a  still 
®  greater  condensation  in  bringing  to  the  reader  the  results  of  the  daily  io  u.uulating 
£  contributions  to  our  knowledge  of  disease  and  its  prevention  or  its  remedies.  To  aoeom- 
^    plish  this  end  The  Journal  of  the  future  here  devotes  itself,    [ta  position  for  the  last 

sixty-eight  years  as  the  authoritative  o/gan  of  the  most  advanced  minds  of  the  profession 
2    offers  the  surest  guarantee  of  its  future  usefulness  under  its  enlarged  opportunities, 
t  Those  friends  who  have  become  attached  to  the  present  form  of  The  Journal  will 

r       be  gratified  to  learn  that  no  change  in  its  shape  and  appearance  has  been  deemed  advin- 


2   Lea  Brothers  &  Co.'s  Periodicals — Am.  Journal,  Medical  News. 


THE  AMERICAN  JOURNAL  of  the  MEDICAL  SCIENCES. 

As  a  Monthly.  (Continued  from  first  page.) 

ble.  Its  total  yearly  size  will  be  somewhat  increased,  while  its  individual  parts  will  be 
smaller  and  more  convenient  for  mental  and  physical  grasp.  A  larger  proportion  of 
space  will  be  devoted  to  Original  Articles,  which  will  be  on  an  average  shorter  than  at 
present,  so  that  every  reader  may  not  fail  to  find  in  each  number  something  of  direct 
interest  to  himself.  The  Department  of  Progress  will  continue  to  furnish  an  able  and 
systematized  epitome  of  the  world's  medical  advance  under  the  headings  of  Anatomy ; 
Physiology ;  Materia  Medica,  Therapeutics  and  Pharmacology ;  Medicine ;  Surgery ; 
Ophthalmology ;  Otology ;  Laryngology  ;  Dermatology ;  Midwifery  and  Gynecology ; 
Medical  Jurisprudence  and  Toxicology,  and  Public  Health,  in  charge  of  specialists  whose 
respective  positions  are  a  sufficient  earnest  that,  while  nothing  of  interest  is  omitted, 
equal  care  is  exercised  that  no  opinion  is  advanced  that  is  not  worthy  of  the  complete 
confidence  of  all  practitioners. 

To  accommodate  the  increase  in  these  two  divisions  The  Journal  will  be  somewhat 
enlarged,  and  the  Department  of  .Reviews  will  be  condensed  without  sacrifice  of  the 
pithiness  and  candor  which  have  marked  its  literary  judgments  in  the  past. 

SUBSCRIPTION  R  ITE  REDUCED  TO  $4.00  PER  ANNUM. 

Basing  their  estimates  upon  the  largely  increased  practical  value  of  a  monthly  as 
compared  with  a  quarterly,  the  publishers  have  decided  that  their  subscribers  shall  have 
the  advantage  of  the  decrease  in  cost  per  copy  effected  by  the  increased  number  to  be 
printed.  It  is  safe  to  say  that  in  no  other  publication  of  its  kind  can  an  investment  be 
made  with  the  certainty  of  so  rich  a  return.  When  taken  in  connection  with  the  weekly 
Medical,  News,  the  reader  can  rest  assured  that  nothing  of  importance  in  the  life  of  the 
great  medical  world  will  escape  his  attention.  To  lead  every  subscriber  to  prove  this  fact 
for  himself,  the  Commutation  rate  has  been  greatly  reduced,  being  fixed  at  the  exceedingly 
low  figure  of  Seven  Dollars  and  Fifty  Cents  Per  Annum  in  Advance. 


THE  MEDICAL  NEWS. 

WEEKLY. 

28  to  32  Quarto  Pages  of  Reading  Matter.     $5.00  per  annum. 

FOUNDED  as  a  monthly  in  1843,  The  Medical  News  assumed  a  weekly  form  in 
1882,  thereby  inaugurating  a  marked  and  permanent  change  in  American  medical 
journalism.  It  undertook  to  supply  a  medical  magazine  and  newspaper  in  the  largest 
and  highest  sense  of  both  terms,  and  to  this  end  its  energies  have  been  devoted  with 
unflagging  assiduity.  Presenting  a  conveniently  large  amount  of  well-digested  matter 
each  week,  it  enables  the  general  practitioner  to  keep  advised  of  the  thought,  experience 
and  discoveries  of  his  colleagues  in  all  parts  of  the  world  at  a  minimum  expense  of  time 
and  money.  Posted  by  its  crisp  journalism,  and  completing  his  knowledge  with  the  more 
elaborate  pages  of  the  Monthly  American  Journal,  the  reader  may  feel  secure  that 
nothing  of  importance  can  escape  him.  To  aid  in  extending  the  advantages  of  this 
combination,  the  publishers  have  decided  to  reduce  the  Commutation  Eate  for  the  two 
periodicals  to  Seven  Dollars  and  Fiity  Cents  Per  Annum  in  Advance. 


TERMS  OF  SUBSCRIPTION  AND  COMMUTATION  RATE. 

The  Medical  News  (weekly)  $5.00  per  annum.  ")  Together  to  one  address, 

The  American  Journal  of  the  Medical  Sciences  \    by  mail,  $7.50  per  an- 
(monthly)  $4.00  per  annum.  J     num,  in  advance. 

*  #  *  Specimen  copies  of  either  of  these  periodicals  will  be  sent,  free  of  cost,  on  application 
to  the  publishers. 


SPECIAL  OFFERS. 

A dvance- paying  subscribers  to  either  or  both  of  the  above-named  periodicals  may  take 
advantage  of  any  one  of  the  following  offers: 

(1).  The  Medical  News  Visiting  List  for  1888,  post-paid  on  receipt  of  75  cents 
per  volume  (regular  price  $1.25).  (2).  The  Year-Book  of  Treatment  for  1886  or  1887 
(see  page  17)  will  be  sent  on  receipt  of  75  cents  (regular  price  $1.25).    (3).  An  advance 


Lea  Brothers  &  Co.'s  Publications — Period.,  Manuals. 


3 


remittance  of  $8.50  will  procure  The  News  and  The  Journal  for  one  year,  together 
with  The  Medical  News  Visiting  List  and  The  Year-Book  of  Treatment  for 
1886  or  1887,  as  offered  above.    Thumb-letter  Index  for  quick  use,  25  cents  additional. 


Subscribers  can  obtain,  at  the  close  of  each  volume,  cloth  covers  for  The  Journal  (one 
annually),  and  for  The  News  (one  annually),  free  by  mail,  by  remitting  Ten  Cents  for  the 
Journal  cover,  and  Fifteen  Cents  for  the  News  cover. 


The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn  to 
the  order  of  the  undersigned ;  where  these  are  not  accessible,  remittances  for  subscriptions 
may  be  sent  at  the  risk  of  the  publishers  by  forwarding  in  registered  letters.  Address, 

LEA  BROTHERS  &  CO.,  706  and  708  Sansom  Street,  Philadelphia. 


THE  MEDICAL  NEWS  VISITING  LIST  FOB  1888 

Has  been  revised  and  brought  thoroughly  up  to  date  in  every  respect.  It  con- 
tains 48  pages  of  text,  including  calendar  for  two  years;  obstetric  diagrams;  scheme 
of  dentition;  tables  of  weights  and  measures  and  comparative  scales;  instructions  for  ex- 
amining the  urine ;  list  of  disinfectants ;  table  of  eruptive  fevers ;  lists  of  new  remedies 
and  remedies  not  generally  used ;  incompatibles,  poisons  and  antidotes ;  artificial  respira- 
tion ;  table  of  doses,  prepared  to  accord  with  the  last  revision  of  the  U.  S.  Pharmacopoeia ; 
an  extended  table  of  Diseases  and  their  remedies,  and  directions  for  ligation  of  ar- 
teries. 176  pages  of  blanks  for  all  records  of  practice  and  erasable  tablet.  Handsomely 
bound  in  limp  Morocco,  with  pocket,  pencil,  rubber  and  catheter  scale. 

The  Medical  News  Visiting-  List  for  1888  is  issued  in  three  styles :  Weekly,  (for 
30  patients) ;  Monthly,  and  Perpetual.  Each,  in  one  volume,  $1.25.  Also,  furnished  with 
Ready  Reference  Thumb-letter  Index  for  quick  use,  25  cents  additional.  For  special 
offers,  including  Visiting  List,  see  above. 


THE  MEDICAL  NEWS  PHYSICIANS9  LEDGER. 

Containing  400  pages  of  fine  linen  "  ledger  "  paper,  ruled  so  that  all  the  accounts  of  a 
large  practice  may  be  conveniently  kept  in  it,  either  by  single  or  double  entry,  for  a  long 
period.  Strongly  bound  in  leather,  with  cloth  sides,  and  with  a  patent  flexible  back, 
which  permits  it  to  lie  perfectly  flat  when  opened  at  any  place.  Price,  $5.00.  Also, 
a  small  special  lot  of  same  Ledger,  with  300  pages.    Price,  $4.00. 


HABTSHOBNE,  HENRY,  A.  M.,  M.  D.,  LL.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thoroughly  revised  and  greatly  improved.    In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.    Cloth,  $4.25 ;  leather,  $5.00. 

The  object  of  this  manual  is  to  afford  a  conven-  I  industry  and  energy  of  its  able  editor.— Boston 
lent  work  of  reference  to  students  during  the  briel  Mchcal  and  Surgical  Journal,  Sept.  3.  1874. 
moments  at  their  command  while  in  attendance  We  can  say  with  the  strictest  truth  that  it  is  the 
upon  medical  lectures'.  It  is  a  favorable  sign  that  best  work  of  the  kind  with  which  we  are  ac- 
it  has  been  found  necessary,  in  a  short  space  of  |  quainted.  It  embodies  in  a  condensed  form  all 
time,  to  issue  a  new  and  carefully  revised  edition,  recent  contributions  to  practical  medicine,  and  is 
The 'illustrations  are  very  numerous  and  unusu-  I  therefore  useful  to  every  ousy  practitioner  through- 
ally  clear,  and  each  part  seems  to  have  received  j  out  our  country,  besides  being  admirably  adapted 
its  due  share  of  attention.  We  can  conceive  such !  to  the  use  of  students  of  medicine.  The  book  is 
a  work  to  be  useful,  not  only  to  students,  but  to]  faithfully  and  ably  executed.— Charleston  Medical 
practitioners  as  well.  It  reflects  credit  upon  the;  Journal,  April,  1875. 


NEILL,  JOHN,  31.  D.,  and  SMITH,  F.  G.,  M.  D., 

Late  Surgeon  to  the  Penna.  Hospital.  Prof,  of  the  Institutes  of  Med.  in  the  Vniv.  of  Penna. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medical 
Science,  for  the  use  and  examination  of  Students.  A  new  edition,  revised  and  improved. 
In  one  large  royal  12mo.  volume  of  974  pages,  with  374  woodcuts.  Cloth,  $4 ;  leather,  $4.75. 


LUDLOW,  J.L.,M.D., 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics.  To  whicn 
is  added  a  Medical  Formulary.  3d  edition,  thoroughly  revised,  and  greatly  enlarged.  In 
one  12mo.  volume  of  816  pages,  with  370  illustrations.    Cloth,  $3.25 ;  leather,  $3.75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


4 


Lea  Brothers  &  Co.'s  Publications— Dictionaries. 


DUNGLISON,  KOBLEY,  M.I)., 

Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science:  Containing 

a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulae  for  Officinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Ki  chard  J.  Dunglison,  M.  D.  In  one  very  large  and 
handsome  royal  octavo  volume  oi  1139  pages.  Cloth,  $6.50;  leather,  raised  bands,  $7.50; 
very  handsome  half  Russia,  raised  bands,  $8. 

The  object  of  the  author,  from  the  outset,  has  not  been  to  make  the  work  a  mere  lexi- 
con or  dictionary  of  terms,  but  to  afford  under  each  word  a  condensed  view  of  its  various 
medical  relations,  and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of 
medical  science.  Starting  with  this  view,  the  immense  demand  which  has  existed  for  the 
work  has  enabled  him,  in  repeated  revisions,  to  augment  its  completeness  and  usefulness, 
until  at  length  it  has  attained  the  position  of  a  recognized  and  standard  authority  wherever 
the  language  is  spoken.  Special  pains  have  been  taken  in  the  preparation  of  the  present 
edition  to  maintain  this  enviable  reputation.  The  additions  to  the  vocabulary  are  more 
numerous  than  in  any  previous  revision,  and  particular  attention  has  been  bestowed  on  the 
accentuation,  which  will  be  found  marked  on  every  word.  The  typographical  arrangement 
has  been  greatly  improved,  rendering  reference  much  more  easy,  and  every  care  has  been 
taken  with  the  mechanical  execution.  The  volume  now  contains  the  matter  of  at  least 
four  ordinary  octavos. 


About  tne  first  book  purchased  by  the  medical 
student  is  the  Medical  Dictionary.  The  lexicon 
explanatory  of  technical  terms  is  simply  a  sine  qua 
non.  In  a  science  so  extensive  and  with  such  col- 
laterals as  medicine,  it  is  as  much  a  necessity  also 
to  the  practising  physician.  To  meet  the  wants  of 
students  and  most  physicians  the  dictionary  must 
be  condensed  while  comprehensive,  and  practical 
while  perspicacious.  It  was  because  Dunglison's 
met  these  indications  that  it  became  at  once  the 
dictionary  of  general  use  wherever  medicine  was 
studied  in  the  English  language.  In  no  former 
revision  have  the  alterations  and  additions  been 
so  great.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps; 
an  arrangement  which  greatly  facilitates  reference. 
— Cincinnati  Lancet  and  Clinic,  Jan.  10, 1874. 

A  book  of  which  every  American  ought  to  be 
proud.    When  the  learned  author  of  the  work 


passed  away,  probably  all  of  us  feared  lest  the  book 
should  not  maintain  its  place  in  the  advancing 
science  whose  terms  it  defines.  Fortunately,  Dr. 
Richard  J.  Dunglison,  having  assisted  his  father  in 
the  revision  of  several  editions  of  the  work,  and 
having  been,  therefore,  trained  in  the  methods 
and  imbued  with  the  spirit  of  the  book,  has  been 
able  to  edit  it  as  a  work  of  the  kind  should  be 
edited — to  carry  it  on  steadily,  without  jar  or  inter- 
ruption, along  the  grooves  of  thought  it  has  trav- 
elled during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and 
carried  through,  it  is  only  necessary  to  state  that 
more  than  six  thousand  new  subjects  have  been 
added  in  the  present  edition. — Philadelphia  Medical 
Times,  Jan.  3, 1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


HOBLYN,  BICHABI)  Z>.,  M.  2>. 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 

Sciences.    Eevised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.    In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.    Cloth,  $1.50 ;  leather,  $2.00. 
It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 

Medical  and  Surgical  Journal. 

STUDENTS9  SEBIES  OF  MANUALS. 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine 
and  Surgery,  written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size 
1 2mo.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price.  The  following  vol- 
umes are  now  ready :  Treves'  Manual  of  Surgery,  by  various  writers,  in  three  volumes, 
each,  $2 ;  Bell's  Comparative  Physiology  and  Anatomy,  $2 ;  Gould's  Surgical  Diagno- 
sis, $2 ;  Robertson's  Physiological  Physics,  $2 ;  Bruce's  Materia  Medica  and  Therapeu- 
tics, $1.50;  Power's  Human  Physiology,  $1.50;  Clarke  and  Lockwood's  Dissectors' 
Manual,  $1.50;  Ralfe's  Clinical  Chemistry,  $1.50;  Treves'  Surgical  Applied  Anatomy,  $2; 
Pepper's  Surgical  Pathology,  $2 ;  and  Klein's  Elements  of  Histology,  $1.50.  The  following 
are  in  press :  Bellamy's  Operative  Surgery,  Pepper's  Forensic  Medicine,  and  Curnow's 
Medical  Applied,  Anatomy.     For  separate  notices  see  index  on  last  page. 

SEBIES  OF  CLINICAL  MANUALS. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the 
profession  with  a  collection  of  authoritative  monographs  on  important  clinical  subjects 
in  a  cheap  and  portable  form.  The  volumes  will  contain  about  550  pages  and  will  be 
freely  illustrated  by  chromo-lithographs  and  woodcuts.  The  following  volumes  are 
now  ready:  Hutchinson  on  Syphilis,  $2.25;  Marsh  on  the  Joints,  $2;  Owen  on 
Surgical  Diseases  of  Children,  $2 ;  Morris  on  Surgical  Diseases  of  the  Kidney,  $2.25  ;  Pick 
on  Fractures  and  Dislocations,  $2 ;  Butlin  on  the  Tongue,  $3.50 ;  Treves  on  Intestinal 
Obstruction,  $2;  and  Savage  od  Insanity  and  Allied  Neuroses,  $2.  The  following  are  in 
active  preparation:  Carter  &  Frost's  Ophthalmic  Surgery,  Bryant  on  the  Breast, 
Broadbent  on  the  Pulse,  Lucas  on  Diseases  of  the  Urethra,  and  Ball  on  the  Rectum  and 
Anus.    For  separate  notices  see  index  on  last  page. 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


5 


Gil  AY,  HEKBY,  F.  It.  Si, 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

Anatomy,  Descriptive  and  Surgical.  The  Drawings  by  H.  V.  Carter,  M.  U, 
and  Dr.  Westmacott.  The  dissections  jointly  by  the  Author  and  Dr.  Carter.  With 
an  Introduction  on  General  Anatomy  and  Development  by  T.  Holmes,  M.  A.,  Surgeon  to 
St.  George's  Hospital.  Edited  by  T.  Pickering  Pick,  F.  R.  C.  S.,  Surgeon  to  and  Lecturer 
on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Royal  College  of 
Surgeons  of  England.  A  new  American  from  the  eleventh  enlarged  and  improved  London 
edition,  thoroughly  revised  and  re-edited  by  William  W.  Keen,  M.  D.,  Professor  of 
Anatomy  in  the  Pennsylvania  Academy  of  the  Fine  Arts,  etc.  To  which  is  added  the 
second  American  from  the  latest  English  edition  of  Landmarks,  Medical  and  Surgi- 
cal, by^  Luther  Holden,  F.  R.  C.  S.  In  one  imperial  octavo  volume  of  about  1100 
pages,  with  about  650  large  and  elaborate  engravings  on  wood.  Price  of  edition  in  black  : 
Cloth,  $6 ;  leather,  $7 ;  half  Russia,  $7.50.  Price  of  edition  in  colors  (see  below) : 
Cloth,  $7.25 ;  leather,  $8.25 ;  half  Russia,  $8.75. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  thi 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engraving 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  In  this  edition  a  new  departure 
will  be  taken  by  the  issue  of  the  work  with  the  arteries,  veins  and  nerves  distinguished 
by  different  colors.  The  engravings  thus  form  a  complete  and  splendid  series,  which  will 
greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recall- 
ing the  details  of  the  dissecting-room.  Combining,  as  it  does,  a  complete  Atlas  of 
Anatomy  with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy, 
the  work  will  be  found  of  great  service  to  all  physicians  who  receive  students  in  their 
offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the  groundwork  of  a 
thorough  medical  education. 

For  the  convenience  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost  necessi- 
tated by  the  use  of  colors,  the  volume  will  be  published  also  in  black  alone,  and  main- 
tained in  this  style  at  the  price  of  former  editions,  notwithstanding  the  largely  increased 
size  of  the  work. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered 
by  type  and  illustration  in  anatomical  study. 


Also  for  sale  separate — 
HOLD  JEW,  LUTHER,  F.  It.  C.  S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals,  London. 
Landmarks,  Medical  and  Surgical.    Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Pennsylvania  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anatomy  in  the  Phila- 
delphia School  of  Anatomy.    In  one  handsome  12mo.  volume  of  148  pages.    Cloth,  $1.00. 

This  little  book  is  all  that  can  be  desired  within  cians  and  surgeons  is  much  to  be  encouraged.  It 
its  scope,  and  its  contents  will  be  found  simply  in-  inevitably  leads  to  a  progressive  education  of  both 
valuable  to  the  young  surgeon  or  physician,  since  the  eye  and  the  touch,  by  which  the  recognition  of 
they  bring  "before  him  such  data  as  he  requires  at  disease  or  t  he  localization  of  injuries  is  vastly  as- 
every  examination  of  a  patient.  It  is  written  in  sisted.  One  thoroughly  familiar  with  the  facts  her* 
language  so  clear  and  concise  that  one  ought  taught  is  capable  of  a  degree  of  accuracy  and  a 
almost  to  learn  it  by  heart.  It  teaches  diagnosis  by  I  confidence  of  certainty  which  is  otherwise  unat- 
external  examination,  ocular  and  palpable,  of  the  tainable.  We  cordially  recommend  the  Landmarks 
body,  with  such  anatomical  and  physiological  facts  to  the  attention  of  every  physician  who  has  not 
as  directly  bear  on  the  subject.  It  is  eminently  I  yet  provided  himself  with  a  copy  of  this  useful, 
the  student's  and  young  practitioner's  book.— Phy  I  practical  guide  to  the  correct  blacing  of  all  the 
sieian  and  Surgeon,  Nov.  1881.  i  anatomical  parts  and  organs.— Canatia  Medical  and 

The  study  of  these  Landmarks  by  both  physi-  !  Surgical  Journal,  Dec.  1881. 

WILSON,  ERASMUS,  F.  R.  S. 

A  System  of  Human  Anatomy,  General  ami  Special  Edited  by  W.  EL 
Gobrecht,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustration*. 
Cloth,  $4.00;  leather,  $5.00.  

CLELAJSTD,  JOHN,  M.  L>.,  F.  R.  S., 

Professor  o  f  Anatomy  ami  Physiology  in  Queen's  College,  Oahvay. 

A  Directory  for  the  Dissection  of  the  Human  Body.  In  one  12mo. 
volume  of  178  pages.    Cloth,  $1.25. 


6 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


ALLEN,  HARBISON,  M.  D., 

Professor  of  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  With  an  Intro- 
ductory Section  on  Histology.  By  E.  O.  Shakespeare,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  Ml  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section  I.  Histology. 
Section  II.  Bones  and  Joints.  Section  III.  Muscles  and  Fascle.  Section  IV. 
Arteries,  Veins  and  Lymphatics.  Section  V.  Nervous  System.  Section  VI. 
Organs  of  Sense,  or  Digestion  and  Genito-Urinary  Organs,  Embryology, 
Development,  Teratology,  Superficial  Anatomy,  Post-Mortem  Examinations, 
and  General  and  Clinical  Indexes.  Price  per  Section,  $3.50 ;  also  bound  in  one 
volume,  cloth,  $23.00 ;  very  handsome  half  Russia,  raised  bands  and  open  back,  $25.00. 
For  sale  by  subscription  only.    Apply  to  the  Publishers. 

Extract  from  Introduction. 

It  is  the  design  of  this  book  to  present  the  facts  of  human  anatomy  in  the  manner  best 
suited  to  the  requirements  of  the  student  and  the  practitioner  of  medicine.  The  author 
believes  that  such  a  book  is  needed,  inasmuch  as  no  treatise,  as  far  as  he  knows,  contains,  in 
addition  to  the  text  descriptive  of  the  subject,  a  systematic  presentation  of  such  anatomical 
facts  as  can  be  applied  to  practice. 

A  book  which  will  be  at  once  accurate  in  statement  and  concise  in  terms ;  which  will  be 
an  acceptable  expression  of  the  present  state  of  the  science  of  anatomy  ;  which  will  exclude 
nothing  that  can  be  made  applicable  to  the  medical  art,  and  which  will  thus  embrace  all 
of  surgical  importance,  while  omitting  nothing  of  value  to  clinical  medicine, — would  appear 
to  have  an  excuse  for  existence  in  a  country  where  most  surgeons  are  general  practitioners, 
and  where  there  are  few  general  practitioners  who  have  no  interest  in  surgery. 


It  is  to  be  considered  a  study  of  applied  anatomy 
In  its  widest  sense — a  systematic  presentation  of 
such  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgery.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of.  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  travelled  over  by  one  thoroughly  famil- 
iar with  it.   The  illustrations  are  madewitft  great 


care,  and  are  simply  superb.  There  is  as  much 
of  practical  application  of  anatomical  points  to 
the  every-day  wants  of  the  medical  clinician  as 
to  those  of  the  operating  surgeon.   In  fact,  few 

?;eneral  practitioners  will  read  the  work  without  a 
eeling  of  surprised  gratification  that  so  many 
points,  concerning  which  they  may  never  have 
thought  before  are  so  well  presented  for  their  con- 
sideration. It  is  a  work  which  is  destined  to  be 
the  best  of  its  kind  in  any  language.— Medical 
Record,  Nov.  25, 1882. 


CLARKE,  W.  B.,  F.R.C.S.  &  LOCKWOOD,C.  B.,  F.R.C.S. 

Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical  School,  London. 
The  Dissector's  Manual.    In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49  illustrations.    Limp  cloth,  red  edges,  $1.50.    See  Students'  Series  of  Manuals,  page  4. 

Messrs.Clarke  and  Lockwood  have  written  a  book 
that  can  hardly  be  rivalled  as  a  practical  aid  to  the 
dissector.  Their  purpose, which  is  "how  to  de- 
scribe the  best  way  to  display  the  anatomical 
structure,"  has  been  fully  attained.  They  excel  in 
a  lucidily  of  demonstration  and  graphic  terseness 
of  expression,  which  only  a  long  training  and 


intimate  association  with  students  could  have 

fiven.  With  such  a  guide  as  this,  accompanied 
y  so  attractive  a  commentary  as  Treves'  Surgical 
Applied  Anatomy  (same  series),  no  student  could 
fail  to  be  deeply  and  absorbingly  interested  in  the 
study  of  anatomy. — New  Orleans  Medical  and  Sur- 
gical Journal,  April,  1884 


TREVES,  FREDERICK,  F.  R.  C.  8., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 

Surgical  Applied  Anatomy.  In  one  pocket-size  12mo.  volume  of  540  pages, 
with  61  illustrations.  Limp  cloth,  red  edges,  $2.00.  See  Students'  Series  of  Manuals, 
page  4. 


He  has  produced  a  work  which  will  command  a 
larger  circle  of  readers  than  the  class  for  which  it 
was  written.  This  union  of  a  thorough,  practical 
acquaintance  with  these  fundamental  branches, 


quickened  by  daily  use  as  a  teacher  and  practi- 
tioner, has  enabled  our  author  to  prepare  a  work 
which  it  would  be  a  most  difficult  task  to  excel. — 
The  American  Practitioner,  Feb.  1884. 


Preparing, 


CVRNOW,  JOHN,  M.  D.,  F.  R.  C.  P., 

Professor  of  Anatomy  at  King's  College,  Physician  at  King's  College  Hospital. 

Medical  Applied  Anatomy.    In  one  pocket-size  12mo.  volume. 

See  Students'  Series  of  Manuals,  page  4. 

BELLAMY,  EDWARD,  F.  R.  C.  S., 

Senior  Assistant- Surgeon  to  the  Charing- Cross  Hospital,  London. 

The  Student's  Guide  to  Surgical  Anatomy:  Being  a  Description  of  the 
most  Important  Surgical  Regions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
operative  Surgery.   In  one  12mo.  volume  of  300  pages,  with  50  illustrations.  Cloth,  $2.25. 


HARTSHORNE'S  HANDBOOK  OF  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.   Cloth,  $1.75. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  two  octavo  volumes  of  1007  pages, 
with  320  woodcuts.   Cloth,  $6.00. 


Lea  Brothers  &  Co.'s  Publications — Physics,  Physiol.,  Anat.  7 


DRAPER,  JOHN  C,  3f.  I).,  LL.  £>., 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 
Medical  Physics.    A  Text-book  for  Students  and  Practitioners  of  Medicine.  In 
one  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.  Cloth,  $4. 

FROM  THE  PREFACE. 
The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admirable 
works  of  Desplats  and  Gariel,  of  Robertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  which  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  placing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  many  years  at  the 
University  of  the  City  of  New  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between- Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 

explained,  acoustics,  optics,  heat,  electricity  and 


This  elegant  and  useful  work  bears  ample  testi- 
mony to  the  learning  and  good  judgment  of  the 
author.  He  has  fitted  his  work  admirably  to  the 
exigencies  of  the  situation  by  presenting  the 
reader  with  brief,  clear  and  simple  statements  of 
such  propositions  as  he  is  by  necessity  required  to 
master.  The  subject  matter  is  well  arranged, 
liberally  illustrated  and  carefully  indexed.  That 
it  will  take  rank  at  once  among  the  text-books  .is 
certain,  and  it  is  to  be  hoped  that  it  will  find  a 
place  upon  the  shelf  of  the  practical  physician, 
where,  as  a  book  of  reference,  it  will  be  found 
useful  and  agreeabio. — Louisville  Medical  News, 
September  26,  1885. 

Certainly  we  have  no  text-book  as  full  as  the  ex- 
cellent one  he  has  prepared.  It  begins  with  a 
statement  of  the  properties  of  matter  and  energy. 
After  these  the  special  departments  of  physics  are 


magnetism,  closing  with  a  section  on  electro- 
biology.  The  applications  of  all  these  to  physiology 
and  medicine  are  kept  constantly  in  view.  The 
text  is  amply  illustrated  and  the  many  difficult 
points  of  the  subject  are  brought  forward  with  re- 
markable clearness  and  ability.— Medical  and  Surg- 
ical Reporter,  July  18,  1885. 

That  this  work  will  greatly  "facilitate  the  study 
of  medical  physics  is  apparent  upon  even  a  mere 
cursory  examination.  It  is  marked  by  that  scien- 
tific accuracy  which  always  characterizes  Dr. 
Draper's  writings.  Its  peculiar  value  lies  in  the 
fact  that  it  is  written  from  the  standpoint  of  the 
medical  man.  Hence  much  is  omitted  that  ap- 
pears in  a  mere  treatise  on  physical  science,  while 
much  is  inserted  of  peculiar  value  to  the  physi- 
cian.— Medical  Record,  August  22,  1885. 


Robertson,  j.  McGregor,  m.  a.,  m.  b., 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 
Physiological  Physics.    In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.   Limp  cloth,  $2.00.    See  Students'  Series  of  Manuals,  page  4. 

The  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
ual for  the  student  of  medicine,  an  auxiliary  to 
his  text-book  in  physiology,  and  it  woul  d  be  particu- 
larly useful  as  a  guide  to  his  laboratory  experi- 


ments. It  will  be  found  of  great  value  to  the 
practitioner.  It  is  a  carefully  prepared  book  of 
reference,  concise  and  accurate,  and  as  such  we 
heartily  recommend  it.— Journal  of  the  American 
Medical  Association,  Dec.  6,  1884. 


n  ALTON,  JOHN  C,  31. I)., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  Neio  York. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.    Cloth,  $2. 


Dr.  Dalton'swork  is  the  fruit  of  the  deep  research 
of  a  cultured  mind,  and  to  the  busy  practitioner  it 
cannot  fail  to  be  a  source  of  instruction.  It  will 
inspire  him  with  a  feeling  of  gratitute  and  admir- 
ation for  those  plodding  workers  of  olden  times, 
who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  as  it  now  stands. —  New  Orleans 
Medical  and  Surgical  Journal,  Aug.  1885. 

In  the  progress  of  physiological  study  no  fact 
was  of  greater  moment,  none  more  completely 


revolutionized  the  theories  of  teachers,  than  the 
discovery  of  the  circulation  of  the  blood.  This 
explains  the  extraordinary  interest  it  has  to  all 
medical  historians.  The  volume  before  us  is  one 
of  three  or  four  which  have  been  written  within  a 
few  years  by  American  physicians.  It  is  in  several 
respects  the  most  complete.  The  volume,  though 
small  in  size,  is  one  of  the  most  creditable  con- 
tributions from  an  American  pen  to  medical  history 
that  has  appeared. — Med.  &  Surg.  Rep.,  Dec.  6, 1884. 


BELL,  F.  JEFFREY,  31.  A., 

Professor  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.  In  one  12mo.  volume  of  561  pages, 
with  229  illustrations.  Limp  cloth,  $2.00.    See  Students'  Series  of  Manuals,  page  4. 

The  manual  is  preeminently  a  student's  book- 
clear  and  simple  in  language  and  arrangement. 
It  is  well  and  abundantly  illustrated,  and  is  read- 
able and  interesting.   On  the  whole  we  consider 


it  the  best  work  in  existence  in  the  English 
language  to  place  in  the  hands  of  the  medical 
student. — Bristol  Medico-Chirurgical  Journal,  Mar., 


ELLIS,  GEORGE  VINER, 

Emeritus  Professor  of  Anatomy  in  University  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  oi  the 
Human  Body  by  Dissection.  From  the  eighth  and  revised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  pages,  with  249  illustrations.  Cloth,  $4.25 ;  leather,  $5.25. 

ROBERTS,  JOHN  B.,  A.  3f.,  M.  1J., 

Prof,  of  Applied  Anat.  and  Oper.  Surg,  in  Phila.  Polyclinic  and  Coll.  for  Ghraduates  in  Medicine. 
The  Compend  of  Anatomy.    For  use  in  the  dissecting-room  ami  in  preparing 
for  examinations.    In  one  16mo.  volume  of  196  pages.    Limp  cloth,  76  cents. 


8      Lea  Brothers  &  Co.'s  Publications — Physiology,  Chemistry. 


CHAPMAN,  HENRY  C.,  M.  J)., 

Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of 
Philadelphia. 

A  Treatise  on  Human  Physiology,    in  one  handsome  octavo  volume  of 

about  1000  pages,  profusely  illustrated.  Shortly. 

DALTON,  JOHN  €.,  M.  L>., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc. 
A  Treatise  on  Human  Physiology.     Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.    Seventh  edition,  thoroughly  revised  and  rewritten.    In  one 
very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00 ;  leather,  $6.00 ;  very  handsome  half  Eussia,  raised  bands,  $6.50. 


This  edition  of  Dr.  Dalton's  well-known  work 
bears  evidence  of  having  been  thoroughly  and 
careiully  revised.  From  the  first  appearance  of 
the  book  it  has  been  a  favorite,  owing  as  well  to 
the  author's  renown  as  an  oral  teacher  as  to  the 
charm  of  simplicity  with  which,  as  a  writer,  he 
always  succeeds  in  investing  even  intricate  sub- 
jects It  must  be  gratifying  to  him  to  observe  the 
frequency  with  which  his  work,written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  fact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  ihe  thou- 
sands who  have  studied  it  in  its  various  editions 
have  never  been  in  .any  doubt  as  to  its  sterling 
worth. — N.  Y.  Medical  Journal  and  Obstetrical  Re- 
view, Oct.  1882. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 


which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — Dublin  Journal  of  Medical  Science,  Feb.'83. 

Certainly  no  physiological  work  as  ever  issued 
from  the  press  that  presented  its  subject-matter  in 
a  clearer  and  more  attractive  light.  Almost  every 
page  bears  evidence  of  the  exhaustive  revision 
that  has  taken  olace.  The  material  is  placed  in  a 
more  compact  form,  yet  its  delightful  charm  is  re- 
tained, and  no  subject  is  thrown  into  obscurity. 
Altogether  this  edition  is  far  in  advance  of  any 
previous  one,  and  will  tend  to  keep  the  profession 
posted  as  to  the  most  recent  additions  to  our 
physiological  knowledge. — Michigan  Medical  News, 
April,  1882. 


FOSTER,  MICHAEL,  M.  D.,  F.  B.  S., 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.    Third  American  from  the  fourth  English  edition? 
with  notes  and  additions  by  E.  T.  Reichert,  M.  D.,  Professor  of  Physiology  in  the  Uni- 
versity of  Pennsylvania.    In  one  handsome  royal  12mo.  volume  of  908  pages,  with  271 
illustrations.   Cloth,  $3.25 ;  leather,  $3.75. 


Dr.  Foster's  work  upon  physiology  is  so  well- 
known  as  a  text-book  in  this  country,  thatitneeds 
but  little  to  be  said  in  regard  to  it.  There  is 
scarcely  a  medical  college  in  the  United  States 
where  it  is  not  in  the  hands  of  the  students.  The 
author,  more  than  any  other  writer  with  whom 
we  are  acquainted,  seems  to  understand  what 
portions  of  the  science  are  essential  for  students 


to  know  and  what  may  be  passed  over  by  them  as 
not  important.  From  the  beginning  to  the  endr 
physiology  is  taught  in  a  systematic  manner.  To 
this  third  American  edition  numerous  additions, 
corrections  and  alterations  have  been  made,  so 
that  in  its  present  form  the  usefulness  of  the  book 
will  be  found  to  be  much  increased. —  Cincinnati 
Medical  News,  July  1885. 


POWER,  HENRY,  M.  B.,  F.  R.  C.  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.     In  one  handsome  pocket-size  12mo.  volume  of  396  pages, 
with  47  illustrations.    Cloth,  $1.50.    See  Students'  Series  of  Manuals,  page  4. 


The  prominent  character  of  this  work  is  that  of 
judicious  condensation,  in  which  an  able  and  suc- 
cessful effort  appears  to  have  been  made  by  its 
accomplished  author  to  teach  the  greatest  number 
of  facts  in  the  fewest  possible  words.  The  result 
is  a  specimen  of  concentrated  intellectual  pabu- 
lum seldom  surpassed,  which  ought  to  be  care- 
fully ingested  and  digested  by  every  practitioner 
who  desires  to  keep  himself  well  informed  upon 
this  most  progressive  of  the  medical  sciences. 
The  volume  is  one  which  we  cordially  recommend 


to  every  one  of  our  readers. — The  American  Jour- 
nal  of  the  Medical  Sciences,  October,  1884. 

This  little  work  is  deserving  of  the  highest 
praise,  and  we  can  hardly  conceive  how  the  main 
facts  of  this  science  could  have  been  more  clearly 
or  concisely  stated.  The  price  of  the  work  is  such 
as  to  place  it  within  the  reach  of  all,  while  the  ex- 
cellence of  its  text  will  certainly  secure  for  it  most 
favorable  commendation — Cincinnati  Lancet  and 
Clinic,  Feb.  16,  1884. 


SIMON,  W.,  Ph.  n.,  M.  D., 

Professor  of  Chemistry  and  Toxicology  in  the  College  of  Physicians  and  Surgeons,  Baltimore,  and 
Professor  of  Chemistry  in  the  Maryland  College  of  Pharmacy. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
In  one  8vo.  vol.  of  410  pp.,  with  16  woodcuts  and  7  plates,  mostly  of  actual  deposits, 
with  colors  illustrating  56  of  the  most  important  chemical  reactions.  Cloth,  $3.00 ;  also 
without  plates,  cloth,  $2.50. 


This  book  supplies  a  want  long  felt  by  students 
of  medicine  and  pharmacy,  and  is  a  concise  but 
thorough  treatise  on  the  subject.  The  long  expe- 
rience of  the  author  as  a  teacher  in  schools  of 
medicine  and  pharmacy  is  conspicuous  in  the 
perfect  adaptation  of  the  work  to  the  special  needs 
of  the  student  of  these  branches.    The  colored 


plates,  beautifully  executed,  illustrating  precipi- 
tates of  various  reactions,  form  a  novel  and  valu- 
able feature  of  the  book,  and  cannot  fail  to  be  ap- 
preciated by  both  student  and  teacher  as  a  help 
over  the  hard  places  of  the  science. — Maryland 
Medical  Journal,  Nov.  22, 1884. 


Wohler's  Outlines  of  Organic  Chemistry.  Edited  by  Fitttg.  Translated 
by  Ira  Remsen,  M.  D.,  Ph.  D.    In  one  12mo.  volume  of  550  pages.    Cloth,  $3. 


LEHMANN'S  MANUAL  OF  CHEMICAL  PHYS- 
IOLOGY. In  one  octavo  volume  of  327  pages, 
with  41  illustrations.   Cloth,  $2.25. 

CARPENTER'S  HUMAN  PHYSIOLOGY.  Edited 
by  Henby  Powee.   In  one  octavo  volume. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
Abuse  of  Alcoholic  Liquors  in  Health  and  Dis- 
ease. With  explanations  of  scientific  words.  Small 
12mo.   178  pages.   Cloth,  60  cents. 

GALLOWAY'S  QUALITATIVE  ANALYSIS. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


FRANKLAND, E.,  2>.  C.  L.,  F.  R.S.,  &JAFF,  F.  R.9  F.  I.  C* 


Professor  of  Chemistry  in  the  Normal  School 
of  Science,  London. 


Assist.  Prof,  of  Chemistry  in  the  Normal 
School  of  Science,  London. 


Inorganic  Chemistry.  In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  plates.    Cloth,  $3.75  ;  leather,  $4.75. 


This  work  should  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certainly  better 
adapted  than  any  work  upon  chemistry, with  which 
we  are  acquainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med- 
icine should  have.  Physicians  who  feel  that  their 
chemical  knowledge  is  behind  the  times,  would 
do  well  to  devote  some  of  their  leisure  time  to  the 
study  of  this  work.  The  descriptions  and  demon- 
strations are  made  so  plain  that  there  is  no  diffi- 
culty in  understanding  them. — Cincinnati  Medical 
News,  January,  1886. 


This  excellent  treatise  will  not  fail  to  take  it* 
place  as  one  of  the  very  best  on  the  subject  of 
which  it  treats.  We  have  been  much  pleased 
with  the  comprehensive  and  lucid  manner  in 
which  the  difficulties  of  chemi  :al  notation  and 
nomenclature  have  been  cleared  up  by  the  writers. 
It  shows  on  every  page  tnat  the  problem  of 
rendering  the  obscurities  of  this  science  easy 
of  comprehension  has  long  and  successfully 
engaged  the  attention  of  the  authors.— Medical 
and  Surgical  Reporter,  October  31,  1885. 


FOWNES,  GEORGE,  Fh.  J). 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em- 
bodying Watts'  Physical  Inorganic  Chemistry.  New  American  edition.  In  one  large 
royal  12mo.  volume  of  1061  pages,  with  168  illustrations  on  wood  and  a  colored  plate. 
Cloth,  $2.75 ;  leather,  $3.25. 


Fownes'  Chemistry  has  been  a  standard  text- 
book upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  text  book  with  medi- 
cal students.  In  this  work  are  treated  fully:  Heat, 
Light  and  Electricity,  including  Magnetism.  The 
influence  exerted  by  these  forces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical  practitioner.  We  can  commend  the 
work  as  one  of  the  very  best  text-books  upon 


chemistry  extant. — Cincinnati  Medical  News,  Oc- 
tober, 1885. 

Of  all  the  works  on  chemistry  intended  for  the 
use  of  medical  students,  Fownes'  Chemistry  i9 
perhaps  the  most  widely  used.  Its  popularity  is 
based  upon  its  excellence.  This  last  edition  con- 
tains all  of  the  material  found  in  the  previous, 
and  it  is  also  enriched  by  the  addition  of  Watts' 
Physical  and  Inorganic  Chemistry.  All  of  the  mat- 
ter is  brought  to  the  present  standpoint  of  chemi- 
cal knowledge.  We  may  safely  predict  for  this 
work  a  continuance  of  the  fame  and  favor  it  enjoys 
among  medical  students. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1886. 


ATTFIELD,  JOEHV,  Fh.  1)., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  etc 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  tenth 
English  edition,  specially  revised  by  the  Author.  In  one  handsome  royal  12mo.  volume 
of  728  pages,  with  37  illustrations.    Cloth,  $2.50 ;  leather,  $3.00. 

A  text-book  which  passes  through  ten  editions 
in  sixteen  years  must  have  good  qualities.  This 
remark  is  certainly  applicable  to  Attfield's  Chem- 
istry, a  book  which  is  so  well  known  that  it  is 
hardly  necessary  to  do  more  than  note  the  appear- 
ance of  this  new  and  improved  edition.  It  seems, 
however,  desirable  to  point  out  that  feature  of  the 
book  which,  in  all  probability,  has  made  it  so 
popular.  There  can  be  little  doubt  that  it  is  its 
thoroughly  practical  character,  the  expression 
being  used  in  its  best  sense.  The  author  under- 
stands what  the  student  ought  to  learn,  and  is  able 


to  put  himself  in  the  student's  place  and  to  appre- 
ciate his  state  of  mind. — American  Chemical  Jour- 
nal, April,  1884. 

It  is  a  book  on  which  too  much  praise  cannot  be 
bestowed.  As  a  text-book  for  medical  schools  it 
is  unsurpassable  in  the  present  state  of  chemical 
science,  and  having  been  prepared  with  a  special 
view  towards  medicine  and  pharmacy,  it  is  alike 
indispensable  to  all  persons  engaged  in  those  de- 
partments of  science.  It  includes  the  whole 
chemistry  of  the  last  Pharmacopoeia. —Pacific  Medi- 
cal and  Surgical  Journal,  Jan.  1884. 


BLOXAM,  CHARLES  L., 

Professor  of  Chemistry  in  King's  College,  London. 

Chemistry,  Inorganic  and  Organic.  New  American  from  the  fifth  Lon- 
don edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.    Cloth,  $3.75  ;  leather,  $4.75. 


Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  oi  matter  so  logical  in  se- 
quence that  the  student  never  has  occasion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  ot 
chemical  principles  and  phenomena,  and  the 
mode  of  conducting  these  experiments.  The  book 
maintains  the  position  it  has  always  held  as  one  oi 


the  best  manuals  of  general  chemistry  tn  the  Eng- 
lish language. — Detroit  Lancet,  Feb.  1884. 

Professor  Bloxam's  book  is  a  very  satisfactory 
one.  We  know  of  no  treatise  on  chemistry  which 
contains  so  much  practical  information  in  the 
same  number  of  pages.  The  book  can  be  readily 
adapted  not  only  to  the  needs  of  those  who  d9sire 
a  tolerably  complete  course  of  chemistry,  but  also 
to  the  needs  of  those  who  desire  only  a  general 
knowledge  of  the  subject.  We  take  pleasure  in 
recommending  this  work  both  as  a  satisfactory 
text  book,  and  sa  useful  book  of  reference.—  Bos- 
ton Medical  and  Surgical  Journal,  June  19, 1884. 


REMSEJY,  IRA,  M.  I).,  Fh.  D., 

Professor  of  Cliemistry  in  the  Johns  Hopkins  University,  Baltimore. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.  New  (third)  and  revised  edition.  In  one  handsome  royal 
12mo.  volume  of  about  250  pages.    In  press. 


10 


Lea  Brothers  &  Co.'s  Publications— -Chemistry. 


CHARLES,  T.  CRANSTOUN,  M.  D.,  F.  C.  S.,  M.  S., 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen's  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  with  38  woodcuts  and  1  colored  plate.    Cloth,  $3.50. 


This  is,  we  believe,  the  first  complete  work  of 
the  kind  in  the  English  language,  and  may  well 
serve  to  show  what  progress  is  being  made  in  medi- 
cine. The  student  will  find  condensed  in  one  vol 
ume  such  a  store  of  knowledge  as  would  formerly 
have  cost  him  much  reading  to  gather  The  book 
will  fully  repay  anyone  to  read,  and  every  library 
should  have  it  for  reference.— New  Orleans  Medical 
and  Surgical  Journal,  April,  1885. 

Dr.  Charles  is  fully  impressed  with  the  import- 
ance and  practical  reach  of  his  subject,  and  he 


has  treated  it  in  a  competent  and  instructive  man- 
ner. We  cannot  recommend  a  better  book  than 
the  present.  In  fact,  it  fills  a  gap  in  medical  text- 
books, and  that  is  a  thing  which  can  rarely  be  said 
nowadays.  Dr.  Charles  has  devoted  much  space 
to  the  elucidation  of  urinary  mysteries.  He  does 
this  with  much  detail,  and  yet  in  a  practical  and 
intelligible  manner.  In  fact,  the  author  has  filled 
his  book  with  many  practical  hints.— Medical  Rec- 
ord, December  20,  1884. 


HOFFMANN,  F.,  A.31.9  Fh.IX,  &  POWER  F.B.,  Fit. T>,, 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chem.  in  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations,  ('loth,  $4.25. 


We  congratulate  the  author  on  the  appearance 
of  the  third  edition  of  this  work,  published  for  the 
first  time  in  this  country  also.  It  is  admirable  and 
the  information  it  undertakes  to  supply  is  both 
extensive  and  trustworthy.  The  selection  of  pro- 
cesses for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  the  descrip- 


tion of  them  singularly  explicit.  Moreover,  it  is 
exceptionally  free  from  typographical  errors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pharma- 
ceutical Journal  and  Transactions,  1883. 


CLOWES,  FRANK,  I).  Sc.,  London, 

Senior  Science- Master  at  the  High  School,  New  castle-under -Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  verv  handsome  royal  12mo.  volume  of  387  pages,  with  55  illustrations.  Cloth, 
$2.50. 


We  may  simply  repeat  the  favorable  opinion 
which  we  expressed  after  the  examination  of  the 
previous  edition  of  this  work.  It  is  practical  in  its 
aims,  and  accurate  and  concise  in  its  statements. 
— American  Journal  of  Pharmacy,  August,  1885. 

The  style  is  clear,  the  language  terse  and  vigor- 
ous.  Beginning  with  a  list  of  apparatus  necessary 


for  chemical  work,  he  gradually  unfolds  the  sub- 
ject from  its  simpler  to  its  more  complex  divisions. 
It  is  the  most  readable  book  of  the  kind  we  have 
yet  seen,  and  is  without  doubt  a  systematic, 
intelligible  and  fully  equipped  laboratory  guide 
and  text-book. — Medical  Record,  July  18,  1885. 


RALFE,  CHARLES  H.,  M.  D.,  F.  R.  C.  P., 

Assistant  Physician  at  the  London  Hospital. 
Clinical  Chemistry.    In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 


illustrations.    Limp  cloth,  red  edges,  $1.50. 

This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the  book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ought  to 
know,  of  the  applications  of  chemistry  in  medi- 


See  Students'  Series  of  Manuals,  page  4. 
cine.  Dr.  Ralfe  is  thoroughly  acquainted  with  the 
latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  harmony  with  the 
modern  scientific  methods  and  spirit. — Medical 
Record,  February  2,  1884. 


CLASSEN,  ALEXANDER, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 
Elementary  Quantitative  Analysis.    Translated,  with  notes  and  additions,  by 
Edgar  F.  Smith.  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.    In  one  12mo.  volume  of  324  pages,  with  36  illust.    Cloth,  $2.00. 


It  is  probably  the  best  manual  of  an  elementary 
nature  extant,  insomuch  as  its  methods  are  the 
best.  It  teaches  by  examples,  commencing  with 
single  determinations,  followed  by  separations, 


and  then  advancing  to  the  analysis  of  minerals  and 
such  products  as  are  met  with  in  applied  chemis- 
try. It  is  an  indispensable  book  for  students  in 
chemistry.— Boston  Journal  of  Chemistry,  Oct.  1878. 


GREENE,  WILLIAM  11.,  M.  !>., 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 
A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.   Based  upon  Bow- 
man's Medical  Chemistry.  In  one  12mo.  volume  of  310  pages,  with  74  illus.  Cloth,  $1.75. 

It  is  a  concise  manual  of  three  hundred  pages,  the  recognition  of  compounds  due  to  pathological 
giving  an  excellent  summary  of  the  best  methods  conditions.  The  detection  of  poisons  is  treated 
of  analyzing  the  liquids  and  solids  of  the  body,  both  with  sufficient  fulness  for  the  purpose  of  thestu- 
for  the  estimation  of  their  normal  constituents  and    dentor  practitioner. — Bdston  Jl.  of  Chem.  June,'80. 


Lea  Brothers  &  Co.'s  Publications — Pharm.,  Mat.  Med.,  Therap.  11 


BRUJSTOW,  T.  LAUDER,  31. IX,  I). Sc.,  F.R.S.,  F.R.C.F., 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  London,  etc. 

A  Text-book  of  Pharmacology,  Therapeutics  and  Materia  Medica ; 
Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
In  one  handsome  octavo  volume  of  1033  pages,  with  188  illustrations.  Cloth,  $5.50 ; 
leather,  $6.50. 


It  is  a  scientific  treatise  worthy  to  be  ranked  with 
the  highest  productions  in  physiology,  either  in 
our  own  or  any  other  language.  Everything  is 
practical,  the  dry,  hard  facts  of  physiology  being 
pressed  into  service  and  applied  to  the  treatment 
of  the  commonest  complaints.  The  information 
is  so  systematically  arranged  that  it  is  available 
for  immediate  use.  The  index  is  so  carefully 
compiled  that  a  reference  to  any  special  point  is 
at  once  obtainable.  Dr.  Brunton  is  never  satisfied 
with  vague  generalities,  but  gives  clear  and  pre 


upon  the  subject  of  Pharmacology  the  compre- 
hensive work  of  Brunton  is  clearly  the  most 
important,  and  is  beyond  question  the  foremost 
English  handbook  of  Materia  Medica  and  Thera- 
peutics since  the  appearance  of  Pereira's  Elements 
of  Materia  Medica  in  1842.  It  is  original  both  in 
the  arrangement  of  the  subjects  and  in  the  mode 
of  treatment,  and  develops  in  a  comprehensive 
manner  the  foundation  principles  of  the  science 
of  Pharmacology  without  leaving  the  needs  of  the 
practitioner  out  of  sight  for  an  instant.    In  fact, 


cise  directions  for  prescribing  the  various  drugs  I  the  author  has  written  a  book  which  deserves  to 


and  preparations.    We  congratulate  students  on 
being  at  last  placed  in  possession  of  a  scientific 
treatise  of  enormous  practical  importance. —  The 
London  Lancet,  June  27,  1885. 
Of  all  the  numerous  publications  of  this  year 


be  known  far  beyond  the  boundaries  of  England, 
and  can  serve  as  a  model  for  the  pharmacological 
works  of  the  continent  on  account  of  its  happy 
combination  of  theory  with  practice  —  Vir chow's 
Jahresbericht,  Berlin,  1886. 


BAR THOL O W,  ROBERTS,  A.  M.,  31.  D.,  LL.  D., 

Professor  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Medical  College  of  Phila- 
delphia. 

New  Remedies  of  Indigenous  Source:  Their  Physiological  Actions  and 
Therapeutical  Uses.    In  one  octavo  volume  of  about  300  pages.  Preparing. 


PARRISH,  EDWARD, 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 
A  Treatise  on  Pharmacy:  designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.    With  many  Formulae  and  Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegastd,  Ph.  G.    In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.    Cloth,  $5 ;  leather,  $6. 

Each  page  bears  evidence  of  the  care  bestowed 


No  thorough-going  pharmacist  will  fail  to  possess 
himself  6f  so  useful  a  guide  to  practice,  and  no 
physician  who  properly  estimates  the  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most  effective  meth- 
ods of  combination  are  concerned,  can  afford  to 
leave  this  work  out  of  the  list  of  their  works  of 
reference.  The  country  practitioner,  who  must 
always  be  in  a  measure  his  own  pharmacist,  will 
find  it  indispensable.— Louisville  Medical  News, 
March  29,  1884. 

This  well-known  work  presents  itself  now  based 
upon  the  recently  revised  new  Pharmacopoeia. 


upon  it,  and  conveys  valuable  information  from 
the  rich  store  of  the  editor's  experience.  In  fact, 
all  that  relates  to  practical  pharmacy — apparatus, 
processes  and  dispensing — has  been  arranged  and 
described  with  clearness  in  its  various  aspects,  so 
as  to  afford  aid  and  advice  alike  to  the  student  and 
to  the  practical  pharmacist.  The  work  is  judi- 
ciously illustrated  with  good  woodcuts — American 
Journal  of  .  Pharmacy,  January,  1884. 

There  is  nothing  to  equal  Parrish's  Pharmacy 
in  this  or  any  other  language.— London  Pharma- 
ceutical Journal. 


HER31AJSTJST,  Dr.  L., 

Professor  of  Physiology  in  the  University  of  Zurich. 
Experimental  Pharmacology.  A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and  with 
extensive  additions,  by  Robert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania. .  In  one  handsome  12mo.  volume  of  199  pages,  with  32 
illustrations.    Cloth,  $1.50. 

MAISCH,  JOHN  31.,  Fhar.  D., 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  New  (3d)  edition,  thoroughly  revised.  In  one  handsome  royal  12mo. 
volume  of  about  550  pages,  with  about  250  illustrations.    Cloth,  $3.  Shortly. 

BRUCE,  J.  MITCHELL,  31.  D.,  F.  R.  C.  F., 

Physician  and  Lecturer  on  Materia  Medwa  and  Therapeutics  at  Charing  Cross  Hospital,  London. 

Materia  Medica  and  Therapeutics.  An  Introduction  to  Rational  Treat- 
ment. Fourth  edition.  In  one  pocket-size  L2mo.  volume  of  591  pages.  Limp  cloth, 
$1.50.    See  Students'  Series  of  Manuals,  page  4. 

GRIFFITH,  ROBERT  EGLESF1ELD,  31.  D. 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  additions,  by  John  M.  Maisch, 
Phar.D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  pages,  with  38  illustrations.    Cloth,  $4.50 ;  leather,  $5.50. 


12       Lea  Brothers  &  Co.'s  Publications — Mat.  Med,,  Therap. 


STILLE,  A.,  M.  I).,  LL.  IX,  &  MA  IS  CM,  J.  M.,  Phar.  I)., 

Professor  Emeritus  of  the  Theory  and  Prac-  Prof,  of  Mat.  Med.  and  Botany  in  Phila. 

tice  of  Medicine  and  of  Clinical  Medicine  College  of  Pharmacy,  Sec'y  to  the  Ameri- 

in  the  University  of  Pennsylvania.  can  Pharmaceutical  Association. 

NEW  (FOURTH)  EDITION. 

The  National  Dispensatory. 

CONTAINING  THE  NATURAL  HISTORY,  CHEMISTRY,  PHARMACY,  ACTIONS  AND  USES  Oh 
MEDICINES,  INCLUDING  THOSE  RECOGNIZED  IN  THE  PHARMACOPCEIAS  OF  THE 
UNITED  STATES,  GREAT  BRITAIN  AND  GERMANY,  WITH  NUMEROUS 
REFERENCES  TO  THE  FRENCH  CODEX. 

Fourth   edition,  revised  to  October,  1886,  and  covering  the  new  British  Pharmacopoeia. 

In  one  magnificent  imperial  octavo  volume  of  1794  pages,  with  311  elaborate 
engravings.  Price  in  cloth,  $7.25  :  leather,  raised  bands,  $8.00;  very  handsome  half 
Eussia,  raised  bands  and  open  back,  $9.00. 

This  work  will  be  furnished  with  Patent  Beady  Beference  Thumb-letter  Index  for  $1.00 

in  addition  to  the  price  in  any  style  of  binding. 

In  this  new  edition  of  The  National  Dispensatory,  all  important  changes  in  the 
recent  British  Pharmacopoeia  have  been  incorporated  throughout  the  volume,  while  in 
the  Addenda  will  be  found,  grouped  in  a  convenient  section  of  24  pages,  all  therapeutical 
novelties  which  have  been  established  in  professional  favor  since  the  publication  of  the 
third  edition  two  years  ago.  Detailed  information  is  thus  given  of  the  following  among 
the  many  drugs  treated:  Antipyrin,  Cocaine  Hydrochlorate,  Cascara  Sagrada,  Fabiana, 
Franciscea,  various  new  Glycerins,  Gymnocladus,  Hydroquinon,  Hypnone,  Iodol,  Jaca- 
randa,  Lanolin,  Menthol,  Phormium,  Sulphophenol,  Thallin  and  Urethan.  In  this 
edition,  as  always  before,  The  National  Dispensatory  may  be  said  to  be  the  represent- 
ative of  the  most  recent  state  of  American,  English,  German  and  French  Pharmacology, 
Therapeutics  and  Materia  Medica. 

The  National  Dispensatory  is  so  well  and  favor-  ]  fully  up  to  the  existing  knowledge  upon  the  sub- 
ably  known  on  both  sides  of  the  Atlantic  that  |  jeet  treated.  Its  references  to  the  British  Phar- 
macopoeia have  been  amended  for  the  late  and 
much-changed  new  edition  of  that  work;  an  "ad- 
denda" of  twenty-five  pages  has  been  appended, 
treating  of  the  latest  and  most  important  addi- 
tions to  the  materia  medica.  This  work  should 
be  in  the  hands  of  every  physician  and  pharma- 
cist.— Boston  31  edical  and  Surgical  Journal,  Feb.  10, 
1887. 

We  think  it  a  matter  for  congratulation  that  the 
profession  of  medicine  and  that  of  pharmacy  have 
shown  such  appreciation  of  this  great  work  as  to  call 
for  four  editions  within  the  comparatively  brief 
period  of  eight  years.  The  matters  with  which  it 
deals  are  of  so  practical  a  nature  that  neither  the 
physician  nor  the  pharmacist  can  do  without  the 
latest  text-books  on  them,  especially  those  that  are 
so  accurate  and  comprehensive  as  this  one.  The 
book  is  in  every  way  creditable  both  to  the  authors 
and  to  the  publishers. — N?w  York  Medical  Journal, 
May  21,  1887. 


scarcely  anything  else  is  left  to  the  reviewer  than 
to  call  attention  to  the  fact  that  another  edition 
of  this  valuable  work  has  made  its  appearance. 
This  last  edi' ion  surpasses  even  its  predecessors 
in  thoroughness  and  accuracy.  The  fact  that  in 
1884,  when  the  third  edition  was  published,  no 
revision  of  the  British  Pharmacopoeia  had  been 
made  for  seventeen  years,  has  necessitated  a 
thorough  going  over  of  the  whole  work  in  order 
that  references  might  correspond  to  the  la><t  re- 
vision of  the  work  of  our  British  cousins.  In 
addition  to  these  changes  is  a  fairly  full  resume",  in 
the  form  of  addenda,  of  the  more  important  drugs 
which  have  come  into  general  use  in  the  last  two 
or  three  years. —  The  American  Journal  of  the  Med- 
ical Sciences,  April,  18K7. 

This,  the  most  comprehensive  of  the  several 
commentaries  on  the  Pharmacopoeias  of  the  United 
States,  Great  Britain  and  Germany  which  has  yet 
appeared,  has  by  this  last  revision  been  brought 


EARQUH ARSON,  ROBERT,  31.  I)., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School. 

A  Guide  to  Therapeutics  and  Materia  Medica.  Third  American  edition, 
specially  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia  by 
Frank  Woodbury,  M.  D.    In  one  handsome  12mo.  volume  of  524  pages.    Cloth,  $2.25. 


Dr.  Farquharson's  Therapeutics  is  constructed 
upon  a  plan  which  brings  before  the  reader  all  the 
essential  points  with  reference  to  the  properties  of 
drugs.  It  impresses  these  upon  him  in  such  a  way 
as  to  enable  him  to  take  a  clear  view  of  the  actions 
oi  medicines  and  the  disordered  conditions  in 
which  they  must  prove  useful.   The  double-col- 


umned pages — one  side  containing  the  recognized 
physiological  action  of  the  medicine,  and  the  other 
the  disease  in  which  observers  (who  are  nearly  al- 
ways mentioned)  have  obtained  from  it  good  re- 
sults— make  a  very  good  arrangement.  The  early 
chapter  containing  rules  for  prescribing  is  excel- 
lent.— Canada  Med.  and  Surg.  Journal,  Dec.  1882. 


EDES,  ROBERT  T.,  M.  D., 

Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Department. 

A  Text-Book  of  Materia  Medica  and  Therapeutics.  In  one  octavo  volume 

of  about  600  pages,  with  illustrations.    In  press. 

STILLE,  ALFRED,  M.  D.,  LL.  D., 

Professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 

Therapeutics  and  Materia  Medica.  A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  including  their  Description  and  History.  Fourth  edition, 
revised  and  enlarged.  In  two  large  and  handsome  octavo  volumes,  containing  1936  pages. 
Cloth,  $10.00;  leather,  $12.00;  very  handsome  half  Eussia,  raised  bands,  $13.00. 


Lea  Brothers  &  Co.'s  Publications — Pathol.,  Histol. 


13 


COATS,  JOSEPH,  M.  D.,  F.  I.  P.  S., 

Pathologist  to  the  Glasgow  Western  Infirmary. 
A  Treatise  on  Pathology.    In  one  very  handsome  octavo  volume  of  829  pages, 
with  339  beautiful  illustrations.    Cloth,  $5.50 ;  leather,  $6.50. 


The  work  before  us  treats  the  subject  of  Path- 
ology more  extensively  than  it  is  usually  treated 
in  similar  works.  Medical  students  as  well  as 
physicians,  who  desire  a  work  for  study  or  refer- 
ence, that  treats  the  subjects  in  the  various  de- 
partments in  a  very  thorough  manner,  but  without 
prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  any  with  which  we  are  acquainted.  It  sets 
forth  the  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,  the  changes  from  a  normal 
condition  effected  in  structures  by  disease,  and 
points  out  the  characteristics  of  various  morbid 
agencies,  so  that  they  can  be  easily  recognized.  But, 
not  limited  to  morbid  anatomy,it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions.   There  is  nothing  belonging  to  its  de- 


partment of  medicine  that  is  not  as  fully  elucidated 
as  our  present  knowledge  will  admit.— Cincinnati 
Medical  News,  Oct.  1883. 

One  of  the  best  features  of  this  reatise  consists 
in  the  judicious  admixture  of  foreign  observation 
with  private  experience.  Thus  the  subject  is 
presented  in  a  harmonious  manner,  facilitating 
the  study  of  single  topics  and  making  the  entire 
volume  profitable  and  pleasant  reading.  The 
author  includes  in  his  descriptions,  general 
pathology  as  well  as  the  special  pathological  histol- 
ogy of  the  different  systems  and  organs.  He  has 
succeeded  in  offering  to  students  and  practition- 
ers a  thoroughly  acceptable  work. — Medical  Record, 
Dec.  22, 1883. 


GREEN,  T.  HE  WHY,  M.  D., 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School,  London. 

Pathology  and  Morbid  Anatomy.  Fifth  American  from  the  sixth  revised 
and  enlarged  English  edition.  In  one  very  handsome  octavo  volume  of  482  pages,  with 
150  fine  engravings.    Cloth,  $2.50. 


The  fact  that  this  well-known  treatise  has  so 
rapidly  reached  its  sixth  edition  is  a  strong  evi- 
dence of  its  popularity.   The  author  is  to  be  con- 

fratulated  upon  the  thoroughness  with  which  he 
as  prepared  this  work.  It  is  thoroughly  abreast 
with  all  the  most  recent  advances  in  pathology. 
No  work  in  the  English  language  is  so  admirably 
adapted  to  the  wants  of  the  student  and  practi- 
tioner as  this,  and  we  would  recommend  it  most 
earnestly  to  every  one. — Nashville  Journal  of  Medi- 
cine and  Surgery  ',  Nov.  1884. 


An  extended  review  of  such  a  well-known  book 
is  unnecessary.  We  had  already  regarded  the 
book  as  a  model  of  its  kind,  and  the  author's  as- 
surance that  he  believes  the  present  edition  to  be 
fully  up  to  date  will  be  received  as  sufficient 
proof  that  nothing  of  importance  has  been  omitted. 
The  book  has  been  most  carefully  revised,  and 
bears  upon  every  page  the  marks  of  the  care  and 
accuracy  that  have  won  for  it  an  international 
reputation. — New  York  Medical  and  Surgical  Jour- 
nal, July  18,  1885. 


WOODHEAD,  G.  SIMS,  M.  D.,  F.  R.  €.  P.  E., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.    A  Manual  for  Students  and  Practitioners.    In  one  beau- 
tiful octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.    Cloth,  $6.00. 

It  forms  a  real  guide  for  the  student  and  practi-  themselves  with  this  manual.  The  numerous 
tioner  who  is  thoroughly  in  earnest  in  his  en-  drawings  are  not  fancied  pictures,  or  merely 
deavor  to  see  for  himself  and  do  for  himself.  To  schematic  diagrams,  but  they  represent  faithfully 
the  laboratory  student  it  will  be  a  helpful  com-  the  actual  images  seen  under  the  microscope, 
panion,  and  all  those  who  may  wish  to  familiarize  The  author  merits  all  praise  for  having  produced 
themselves  with  modern  methods  of  examining  a  valuable  work.— Medical  Record,  May  31,  1884. 
morbid  tissues  are  strongly  urged  to  provide 


HCHAFER,  EDWARD  A.,  F.  R.  S., 

Assistant  Professor  of  Physiology  in  University  College,  London. 

The  Essentials  of  Histology.  In  one  octavo  volume  of  246  pages,  with 
281  illustrations.    Cloth,  $2.25. 

an  elementary  text-book  of  histology,  comprising 
all  the  essential  facts  of  the  science,  but  omitting 
unimportant  details.  The  author  has  recom- 
mended only  those  methods  upon  which  long  ex- 
perience has  proved  that  full  dependence  can  be 
placed.  The  strict  observance  of  this  plan  per- 
mits of  no  doubt,  and  makes  the  work  eminently 
satisfactory. —  The  Physician  and  Surgeon,  July,  1887. 


This  admirable  work  was  greatly  needed.  To 
those  who  are  familiar  with  the  author's  former 
"Course  of  Practical  Histology,"  the  book  needs 
no  recommendation.  It  has  been  written  with  the 
object  of  supplying  the  student  with  directions 
for  the  microscopical  examination  of  the  tissues, 
which  are  given  in  a  clear  and  understandable 
way.  Although  especially  adapted  for  laboratory 
work,  at  the  same  time  it  is  intended  to  serve  as 


KLEIN,  E.,  M.  D.,  F.  R.  S., 

Joint  Lecturer  on  General  Anat.  and  Phys.  in  the  Med.  School  of  St.  Bartholomew's  LTosp.,  London. 
Elements  of  Histology.  In  one  pocket-size  12mo.  volume  of  360  pages,  with  181 
illus.   Limp  cloth,  red  edges,  $1.50.    See  Students?  Series  of  Manuals,  page  4. 


This  little  volume,  originally  intended  by  its 
able  author  as  a  manual  for  medical  students, 
contains  much  valuable  information,  systematic- 
ally arranged,  that  will  be  acceptable  to  the 

feneral  practitioner.  It  gives  a  graphic  and  lucid 
escription  of  every  tissue  and  organ  in  the  hu- 


man body;  and,  while  small  in  size,  it  is  full  to 
overflowing  with  important  facts  in  regard  to  these 
multiform  and  complex  structures.  We  know  of 
no  book  of  its  size  that  will  prove  of  greater  va'ue 
to  medical  students  and  practitioners  of  medi- 
cine.— The  Southern  Practitioner,  Nov.  1883. 


PEPPER,  A.  J.,  M.  B.,  M.  S.,  F.  R.  C.  S., 

Surgeon  and  Lecturer  at  St.  Mary's  Hospital,  London. 
Surgical  Pathology.    In  one  pocket-size  12mo.  volume  of  511  pages,  with  81 
illustrations.  Limp  cloth,  red  edges,  $2.00.    See  Students'  Series  of  Manuals,  page  4 


It  is  not  pretentious,  but  it  will  serve  exceed- 
ingly well  as  a  book  of  reference.  It  embodies  a 
great  deal  of  matter,  extending  over  the  whole 
field  of  surgical  pathology.  Its  form  is  practical, 
its  language  is  clear,  and  the  information  set 
forth  is  well-arranged,  well-indexed  and  well- 


illustrated.  The  student  will  find  in  it  nothing 
that  is  unnecessary.  The  list  of  subjects  covers 
the  whole  range  of  surgery.  The  book  supplies  a 
very  manifest  want  and  should  meet  witn  suc- 
cess.— New  York  Medical  Journal,  May  31,  1884. 


Cornil  and  Ranvier's  Pathological  Histology.  —  Translated  by  E.  O. 
Shakespeare,  M.  D.,  and  J.  Henry  C.  Simes,  M.  D.  Octavo,  800  pp.,  360  illustrations 


14 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


ILINT,  AUSTIN,  M.  D.,  LL.  D. 

Prof,  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med.  in  Bellevve  Hospital  Medical  College,  N.  7. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  of  Medicine.  New  (sixth)  edition,  thoroughly  re- 
vised and  rewritten  by  the  Author,  assisted  by  William  H.  Welch,  M.  D.,  Professor  of 
Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Flint,  Jr.,  M.  D.,  LL.  D., 
Professor  of  Physiology,  Bellevue  Hospital  Medical  College,  N.  Y.  In  one  very  handsome 
octavo  volume  of  about  1170  pages,  with  illustrations.  Cloth,  $5.50;  leather,  $6.50; 
very  handsome  half  Russia,  raised  bands,  $7.00. 


A  new  edition  of  a  work  of  such  established  rep- 
utation as  Flint's  Medicine  needs  but  few  words  to 
commend  it  to  notice.  It  may  in  truth  be  said  to 
embody  the  fruit  of  his  labors  in  clinical  medicine, 
ripened  by  the  experience  of  a  long  life  devoted  to 
its  pursuit.  America  may  well  be  proud  of  having 
produced  a  man  whose  indefatigable  industry  and 
gifts  of  genius  have  done  so  much  to  advance  med- 
icine ;  and  all  English-reading  students  must  be 

f rateful  for  the  work  which  he  has  left  behind  him. 
t  has  few  equals,  either  in  point  of  literary  excel- 
lence, or  of  scientific  learning,  and  no  one  can  fail 
to  study  its  pages  without  being  struck  by  the  lu- 
cidity and  accuracy  which  characterize  them.  It 
is  qualities  such  as  these  which  render  it  so  valu- 
able for  its  purpose,  and  give  it  a  foremost  place 
among  the  text-books  of  this  generation. —  The 
London  Lancet,  March  12,  1887. 

No  text-book  on  the  principles  and  practice  of 
medicine  has  ever  met  in  this  country  with  such 


general  approval  by  medical  students  and  practi- 
tioners as  the  work  of  Professor  Flint.  In  all  the 
medical  colleges  of  the  United  States  it  is  the  fa- 
vorite work  upon  Practice;  and,  as  we  have  stated 
before  in  alluding  to  it,  there  is  no  other  medical 
work  that  can  be  so  generally  found  in  the  libra- 
ries of  physicians.  In  every  state  and  territory 
of  this.vast  country  the  book  that  will  be  most  likely 
to  be  found  in  the  office  of  a  medical  man,  whether 
in  city,  town,  village,  or  at  some  cross-roads,  is 
Flint's  Practice.  We  make  this  statement  to  a 
considerable  extent  from  personal  observation,  and 
it  is  the  testimony  also  of  others.  An  examina- 
tion shows  that  very  considerable  changes  have 
been  made  in  the  sixth  edition.  The  work  may  un- 
doubtedly be  regarded  as  fairly  representing  the 
present  state  of  the  science  of  medicine,  and  as 
reflecting  the  views  of  those  who  exemplify  in 
their  practice  the  present  stage  of  progress  of  med- 
ical art. — Cincinnati  Medical  News,  Oct.  1886. 


HARTSHORNE,  HENRY,  31.  D.,  LL.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.    Cloth,  $2.75;  half  bound,  $3.00. 


Within  the  compass  of  600  pages  it  treats  of  the 
history  of  medicine,  general  pathology,  general 
symptomatology,  and  physical  diagnosis  (including 
laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  it  is  one  of  the  best 
•of  its  kind  that  we  have  seen. — Glasgow  Medical 
Journal,  Nov.  1882. 

An  indispensable  book.  No  work  ever  exhibited 
a  better  average  of  actual  practical  treatment  than 


this  one;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials, as  the  name  suggests,  are  not  intended  to 
supersede  the  text-books  of  Flint  and  Bartholow, 
but  they  are  the  most  valuable  in  affording  the 
means  to  see  at  a  glance  the  whole  literature  of  any 
disease,  and  the  most  valuable  treatment.— -Chicago 
Medical  Journal  and  Examiner,  April,  1882. 


B  MIS  TO  WE,  JOHN  STER,  M.  IX,  F.  R.  C.  P., 

Physician  and  Joint  Lecturer  on  Medicine  at  St.  Thomas'  Hospital,  London. 
A  Treatise  on  the  Practice  of  Medicine.    Second  American  edition,  revised 
by  the  Author.  Edited,  with  additions,  by  James  H.  Hutchinson,  M.D.,  physician  to  the 
Pennsylvania  Hospital.    In  one  handsome  octavo  volume  of  1085  pages,  with  illustrations. 
Cloth,  $5.00;  leather,  $6.00;  very  handsome  half  Russia,  raised  bands,  $6.50. 


The  book  is  a  model  of  conciseness,  and  com- 
bines, as  successfully  as  one  could  conceive  it  to 
be  possible,  an  encyclopaedic  character  with  the 
smallest  dimensions.  It  differs  from  other  admi- 
rable lext-books  in  the  completeness  with  which 
it  covers  the  whole  field  of  medicine. — Michigan 
Med  cal  News,  May  10, 1880. 

His  accuracy  in  the  portraiture  of  disease,  his 
care  in  stating  subtle  points  of  diagnosis,  and  the 
faithfully  given  pathology  of  abnormal  processes 
have  seldom  been  surpassed.  He  embraces  many 
diseases  not  usually  considered  to  belong  to  theory 


and  practice,  as  skin  diseases,  syphilis  and  insan- 
ity, but  they  will  not  be  objected  to  by  readers,  as 
he  has  studied  them  conscientiously,  and  drawn 
from  the  life. — Medical  and  Surgical  Reporter,  De- 
cember 20,  1879. 

The  reader  will  find  every  conceivable  subject 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  style  at  once  clear,  interesting  and 
concise.  The  additions  made  by  Dr.  Hutchinson 
are  appropriate  and  practical,  and  greatly  add  to 
its  usefulness  to  American  readers.— Buffalo  Med- 
ical and  Surgical  Journal,  March,  1880. 


WATSON,  SIR  THOMAS,  31.  I)., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 
from  the  fifth  English  edition.  Edited,  with  additions,  and  190  illustrations,  by  Henry 
Hartshorne,  A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
In  two  large  octavo  volumes  of  1840  pages.    Cloth,  $9.00  ;  leather,  $11.00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  Hudson,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.   Cloth,  $2.50. 

STOKES'  LECTURES  ON  FEVER.  Edited  by 
John  William  Moore,  M.  D.,  F.  K.  Q.  C.  P.  In 
one  octavo  volume  of  280  pages.   Cloth,  $2.00. 


A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.    In  one  8vo.  vol.  of  354  pp.   Cloth,  $2.25. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.   Cloth,  $7.00. 


A  CENTURY  OF  AMERICAN  MEDICINE,  1776—1876.  By  Drs.  E.  H.  Clarke,  H.  J. 
Biqelow,  8.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.   In  one  12mo.  volume  of  370  pages.   Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications — System  of  Med. 


15 


For  Sale  by  Subscription  Only. 


A  System  of  Practical  Medicine. 

BY  AMERICAN  AUTHORS. 

Edited  by- WILLIAM  PEPPER,  M.  D.,  LL.  D., 


PROVOST  AND  PROFESSOR  OF  THE  THEORY  AND  PRACTICE  OF  MEDICINE  AND  OF 
CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA, 

by  Loins  Starr,  M.  D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania. 

The  complete  vjork,  in  five  volumes,  containing  5573  pages,  with  198  illustrations,  is  just  ready. 
Price  per  volume,  cloth,  $5 ;  leather,  $6 ;  half  Russia,  raised  bands  and  open  back,  $7. 


In  this  great  work  American  medicine  is  for  the  first  time  reflected  by  its  worthiest 
teachers,  and  presented  in  the  full  development  of  the  practical  utility  which  is  its  pre- 
eminent characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  for  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  to  each  author  has  been 
assigned  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientific  and  practical  knowledge.  The 
practitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  and  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  found  most 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5600  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary 
octavos.    Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

A  detailed  prospectus  will  be  sent  to  any  address  on  application  to  the  publishers. 

These  two  volumes  bring  this  admirable  work  physicians  who  are  acquainted  with  all  the  varie- 
to  a  close,  and  fully  sustain  the  high  standard 
reached  by  the  earlier  volumes;  we  have  only 
therefore  to  echo  the  eulogium  pronounced  upon 
them.  We  would  warmly  congratulate  the  editor 
and  his  collaborators  at  the  conclusion  of  their 
laborious  task  on  the  admirable  manner  in  which, 
from  first  to  last,  they  have  performed  their  several 
duties.  They  have  succeeded  in  producing  a 
work  which  will  long  remain  a  standard  work  of 
reference,  to  which  practitioners  will  look  for 
guidance,  and  authors  will  resort  to  for  facts. 
From  a  literary  point  of  view,  the  work  is  without 
any  serious  blemish,  and  in  respect  of  production,  I 


ties  of  climate  in  the  United  States,  the  character 
of  the  soil,  the  manners  and  customs  of  the  peo- 
ple, etc.,  it  is  peculiarly  adapted  to  the  wants 
of  American  practitioners  of  medicine,  and  it 
seems  to  us  that  every  one  of  them  wou.d  desire 
to  have  it.  It  has  been  truly  called  a  "Complete 
Library  of  Practical  Medicine,"  and  the  general 
practitioner  will  require  little  else  in  his  round 
of  professional  duties. — Cincinnati  Medical  News, 
March,  1886. 

Each  of  the  volumes  is  provided  with  a  most 
copious  index,  and  the  work  altogether  promises 
to  be  one  which  will  add  much  to  the  medical 
it  has  the  beautiful  finish  that  Americans  always  j  literature  of  the  present  century,  and  reflect  ^reat 
give  their  works.— Edinburgh  Medical  Journal,  Jan.  credit  upon  the  scholarship  and  practical  acumen 
1887.  of  its  authors.—  The  London  L'incet,  Oct.  3,  1885. 


*  *  The  greatest  distinctively  American  work  on 
the  practice  of  medicine,  and,  indeed,  the  super- 
lative adjective  would  not  be  inappropriate  were 
even  all  other  productions  placed  in  comparison. 
An  examination  of  the  five  volumes  is  sufficient 
to  convince  one  of  the  magnitude  of  the  enter- 
prise, and  of  the  succes-j  which  has  attended  its 
fulfilment.—  The  Medical  Aqe,  July  26,  1886. 

This  huge  volume  forms  a  fitting  close  to  the 
great  system  of  medicine  which  in  so  short  a  time 
has  won  so  high  a  place  in  medical  literature,  and 
has  done  such  credit  to  the  profession  in  tnis 
country.  Among  the  twenty-three  contributors 
are  the  names  of  the  leading  neurologists  in 
America,  and  most  of  the  work  in  the  volume  is  of 
the  highest  order. — Boston  Medical  and  Surgical 
Journal,  July  21, 1887. 

We  consider  it  one  of  the  grandest  works  on 
Practical  Medicine  in  the  English  language.  It  is 
a  work  of  which  the  profession  of  this  country  can 
feel  proud.    Written  exclusively  by  American 


The  feeling  of  proud  satisfaction  with  which  the 
American  profession  sees  this,  its  representative 
system  of  practical  medicine  issued  to  the  medi- 
cal world,  is  fully  justified  by  the  character  of  the 
work.  The  entire  caste  of  the  system  is  in  keep- 
ing with  the  best  thoughts  of  the  leaders  and  fol- 
lowers of  our  home  school  of  medicine,  and  the 
combination  of  the  scientific  study  of  disease  and 
the  practical  application  of  exa>;t  and  experimen- 
tal knowledge  to  the  treatment  of  human  mal- 
adies, makes  every  one  of  us  share  in  the  pride 
that  has  welcomed  Dr.  Pepper's  labors.  Sheared 
of  the  prolixity  that  wearies  the  readers  of  the 
German  school,  the  articles  glean  these  same 
fields  for  all  that  is  valuable.  It  is  the  outcome 
of  American  brains,  and  is  marked  throughout 
by  much  of  the  sturdy  independence  of  thought 
and  originality  that  is  a  national  characteristic. 
Yet  nowhere  is  there  lack  of  study  of  the  most 
advanced  views  of  the  day. —North  Carolina  Medi- 
cal Journal,  Sept.  1886. 


16        Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 


FOTJBERGILL,  J.  M.,  M.  V.,  Edwi,.  M.  It.  C.  JP.,  Lond., 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics. New  (third)  edition.  In  one  octavo  volume  of  661  pages.  Cloth,  $3.75 ;  leather, 
$4.75.   Just  ready. 

greatly  increased  by  the  introduction  of  many 
prescriptions.  That  the  profession  appreciates 
that  the  author  has  undertaken  an  important  work 
and  has  accomplished  it  is  shown  by  the  demand 
for  this  third  edition.— New  York  Medical  Journal, 
June  11,  1887. 

This  is  a  wonderful  book.  If  there  be  such  a 
thing  as  "medicine  made  easy,"  this  is  the  work 
to  accomplish  this  result.  It  imparts  information 
so  agreeably,  so  smoothly,  that  the  reader  almost 
thinks  as  he  lays  the  book  down  that  he  "knew 
that  before,"  when  in  reality  he  did  not,  or  else  he 
could  before  have  reconciled  facts  which  now 
become  clear  as  daylight.  The  author  deals  with 
the  "Principles  of  Therapeutics,"  the  study  of 
which  will  give  great  vantage  to  the  physician.— 
Virginia  Medical  Monthly ,  June,  1887. 


Dr.  Fothergill  is  always  interesting  and  instruct- 
ive, and  in  this  standard  work  he  shows  his 
peculiar  power  as  a  writer  on  therapeutics  to  the 
best  advantage.  Everything  he  undertakes  is 
done  conscientiously.  The  book  well  sustains 
the  favorable  impression  which  it  created  at  the 
beginning  of  its  career,  and  in  its  present  im- 
proved form  it  will  be  welcomed  more  than  ever 
by  the  busy  practitioner  and  the  scientific  student 
of  medicine.—  The  Medical  News,  July  23,  1887. 

To  have  a  description  of  the  normal  physiologi- 
cal processes  of  an  organ  and  of  the  methods  of 
treatment  of  its  morbid  conditions  brought 
together  in  a  single  chapter,  and  the  relations 
between  the  two  clearly  stated,  cannot  fail  to  prove 
a  great  convenience  to  many  thoughtful  but  busy 
physicians.   The  practical  value  of  the  volume  is 


REYNOLDS,  J.  RUSSELL,  M.  D., 

Protestor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 
A  System  of  Medicine.  With  notes  and  additions  by  Henry  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  double-columned  pages,  with  317  illustra- 
tions. Price  per  volume,  cloth,  $5.00 ;  sheep,  $6.00 ;  very  handsome  half  Russia,  raised  bandsv 
$6.50.    Per  set,  clotb,  $15;  leather,  $18;  half  Russia,  $19.50.    Sold  only  by  subscription. 

&TILLE,  ALFRED,  M.  D.,  LL.  D., 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penno. 
Cholera :  Its  Origin,  History,  Causation,  Symptoms,  Lesions,  Prevention  and  Treat- 
ment. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart.  Cloth,  $1.25. 


FIJSTLAYSOW,  JAMES,  M.  D.,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

Clinical  Manual  for  the  Study  of  Medical  Cases.  With  Chapters 
by  Prof.  Gairdner  on  the  Physiognomy  of  Disease;  Prof.  Stephenson  on  Diseases  of 
the  Female  Organs;  Dr.  Robertson  on  Insanity;  Dr.  Gemmell  on  Physical  Diagnosis; 
Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor  on  Case- 
taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  New  edition. 
In  one  12mo.  volume  of  682  pages,  with  158  illustrations.   Cloth,  $2.50. 


The  profession  cannot  but  welcome  the  second 
edition  of  this  very  valuable  work  of  Finlayson 
and  his  collaborators.  The  size  of  the  book  has 
been  increased  and  the  number  of  illustrations 
nearly  doubled.  The  manner  in  which  the  sub- 
ject is  treated  is  a  most  practical  one.  Symptoms 
alone  and  their  diagnostic  indications  form  the 
basis  of  discussion.  The  text  explains  clearly  and 
thoroughly  the  methods  of  examination  and  the 
conclusions  to  be  drawn  from  the  physical  signs.— 
The  Medical  News,  April  23, 1887. 

This  manual  is  one  of  the  most  complete  and 
perfect  of  its  kind.  It  goes  thoroughly  into  the 
question  of  diagnosis  from  every  possible  point. 
It  must  lead  to  a  thoroughness  of  observation,  an 
examination  in  detail  of  every  scientific  appliance, 


and  a  study  of  means  to  the  end  which  cannot 
fail  in  laying  an  excellent  foundation  for  the 
student  for  future  success  as  an  able  diagnostician. 
— Medical  Record,  August  13, 1887. 

The  second  edition  of  this  manual  is  a  very 
considerable  improvement  upon  the  first.  Much 
new  matter  has  been  introduced  and  the  work  has 
been  brought  up  to  the  present  time  in  all  respects. 
As  it  stands  it  is  one  of  the  best  manuals  of  diag- 
nosis in  the  English  language  for  beginners.  The 
whole  work  is  so  complete  and  so  simply  written, 
and  yet  contains  such  an  amount  of  valuable 
information,  that  it  should  be  a  part  of  the  library 
of  every  practitioner.— New  York  Medical  Journal. 
July  23,  1887. 


FENWICK,  SAMUEL,  M.  D., 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  English  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.    Cloth,  $2.25. 

JELABERSHON,  S.  O.,  M.  D., 

Senior  Physician  to  and  late  Led.  on  Principles  and  Practice  of  Med.  at  Guy's  Hospital,  London. 

On  the  Diseases  of  the  Abdomen ;  Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.  In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.    Cloth,  $3.50. 

TANWER,  THOMAS  HAWKES,  M.  D. 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
from  the  second  London  edition.  Revised  and  enlarged  by  Tilbury  Fox,  M.  D. 
In  one  small  12mo.  volume  of  362  pages,  with  illustrations.    Cloth,  $1.50. 


Lea  Brothers  &  Co.'s  Publications — Hygiene,  Eleetr.,  Pract. 


17 


BART  HO  LOW,  ROBERTS,  A.  M.,  M.  L>.,  LL.  I)., 

Prof,  of  Materia  Medica  and  Oenerai  Therapeutics  in  the  Jefferson  Med.  Coil,  of  Phila.,  etc. 
Medical  Electricity.    A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.    JSTew  (third)  edition.    In  one  very  handsome  octavo  volume  of 
308  pages,  with  110  illustrations.    Cloth,  $2.50.    Just  ready. 


The  fact  that  this  work  has  reached  its  third  edi- 
tion in  six  years,  and  that  it  has  been  kept  fully 
abreast  with  the  increasing  u*e  and  knowledge  of 
e!ectricity,demonstrates  its  claim  to  be  considered 
a  practical  treatise  of  tried  value  to  the  profession. 
The  matter  added  to  the  present  ediiion  embraces 
the  most  recent  advances  in  electrical  treatment. 
The  illustrations  are  abundant  and  clear,  and  the 
work  constitutes  a  full,  clear  and  concise  manual 
well  adapted  to  the  needs  of  both  student  and 
practitioner.—  The  Medical  News,  May  14,  1887. 

This  "practical  treatise  on  the  applications  of 
electricity  to  medicine  and  surgery"  has  grown  to 
be  so  important  a  work  that  every  practitioner 


should  read  it,  especially  when  it  is  recalled  what 
possibilities  lie  in  the  path  of  the  further  study  of 
the  therapeutics  of  electricity.  Dr.  Bartholow  has 
here  presented  the  profession  with  a  concise  work 
that,  beginning  with  elementary  descriptions  and 
principles,  gradually  grows,  page  by  page,  into  a 
magnificently  practical  treatise/describing  opera- 
tions in  detail,  and  giving  records  of  successes 
that  prove  electricity  to  be  marvellous  as  a  curative 
agent  in  many  forms  of  disease.  The  doctor  can- 
not now  do  better  than  to  possess  himself  of  Dr. 
Bartholow's  treatise,  just  as  it  is.!-"- Virginia  Mtdir 
cal  Monthly,  June,  1887. 


RICHARDS  ON,  B.  W.,  M.A.,  M.H.,  LL.  L>.,  F.R.S.,  F.S.A. 

Fellow  of  the  Royal  College  of  Physicians,  I<ondon. 
Preventive  Medicine.    In  one  octavo  volume  of  729  pages.    Cloth,  $4 ;  leather, 
$5;  very  handsome  half  Russia,  raised  bands,  $5.50. 

tive  collection  of  data  upon  the  diseases  common 
to  the  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly  ;  the  discussion  of 


Dr.  Richardson  has  succeeded  in  producing  a 
work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  character,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.  He  evinces  the  happy 
faculty  or  extracting  the  pith  of  what  is  known  on 
the  subject,  and  of  presenting  it  in  a  most  simple, 
intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  the  general  public 
thatcontains  such  a  complete,  reliable  and  instruc- 


tive question  of  disease  is  comprehensive,  masterly 
and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable.—  The 
American  Journal  of  the  Medical  Sciences,  April,  1884. 


HARTSHORNE,  H JEWRY,  M.  L>.,  LL.  IX, 

Formerly  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  and  Professor  of  Physiology  and 
Diseases  of  Children  in  the  Woman's  Medical  College  of  Pennsylvania. 

A  Household  Manual  of  Medicine,  Surgery,  Nursing  and  Hygiene: 
For  Daily  Use  in  the  Preservation  of  Health  and  Care  of  the  Sick  and  Injured,  with  an 
Introductory  Outline  of  Anatomy  and  Physiology.  In  one  very  handsome  royal  octavo 
volume  of  946  pages,  with  8  plates  and  283  engravings.  Cloth,  $4.00 ;  very  handsome 
half  Morocco,  $5.00.   

THE  YEAR-BOOK  OF  TREATMENT  FOR  1886. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine.   In  one  12mo.  volume  of  309  pages,  bound  in  limp  cloth,  $1.25. 


This  "review"  includes  every  department  of 
medical  and  surgical  as  well  as  obstetrical  practice. 
It  attempts  nothing  in  the  way  of  etiology,  diag- 
nosis or  symptoms,  but  limits  itself  to  the  ad- 
vances made  in  the  treatment  of  diseases,  injuries, 
etc.   The  work  seems  to  us  to  be  invaluable  to 


every  practitioner,  whether  he  be  a  general  one  or 
a  specialist.  It  is  a  book  to  be  kept  on  the  office 
table  for  continuous  reference.  An  excellent  in- 
dex to  subjects,  as  well  as  to  authors  quoted,  is 
appended. —  Virginia  Medical  Monthly,  April,  1887. 


x\  For  special  commutations  with  periodicals  see  page  3. 


THE  YEAR-BOOK  OF  TREATMENT  FOR  1885. 

Similar  to  that  of  1886  above.    12mo.,  320  pages.    Limp  cloth,  $1.25. 

SCHREIBER,  DR.  JOSEPH. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Walter  Mendelson,  M.  D.,  of  New  York.  In  one  handsome 
octavo  volume  of  278  pages,  with  117  fine  engravings.    Just  ready.    Cloth,  $2.75. 


The  present  volume  will  do  much  to  establish 
mechanical  therapeutics  upon  a  scientific  basis. 
The  work  is  a  very  welcome  addition  to  the  library, 
and  we  heartily  recommend  it  to  our  readers  as 
a  step  in  the  right  direction. — New  York  Medical 
Journal,  Julj  16,  1887. 

As  a  thorough  and  satisfactory  exposition  of  the 


science  of  mechanical  therapeutics,  adapted  to 
the  use  of  the  general  practitioner,  this  volume 
leaves  nothing  to  be  desired.  The  text  is  fully 
illustrated  by  well-drawn  woodcuts,  leaving  no 
room  for  obscurity  in  the  description  of  the  vari- 
ous manipulations  recommended. — Atlanta  Medi- 
cal and  Surgical  Journal,  Aug.  1887. 


STURGES'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
l2mo.  volume  of  127  pages.   Cloth,  $1.25. 

DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  S.  Davib, 
M.  D.  Edited  by  Frank  H.  Davis,  M.  D.  Second 
edition.   l2mo.  287  pages.   Cloth,  $1.75. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.    In  one  octavo  volume  of 
Cloth,  $2.50. 


PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION ;  its  Disorders  and  their  Treatment 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  page9.    Cloth.  $2.00. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Condi*. 
M.  D.    1  vol.  8vo.,  pp.  603.    Cloth,  $2.50. 

CHAMBERS'  MANUALOF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.   Cloth,  $2.76. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8TO.,  pp.  493.    Cloth,  $3.50. 


18 


Lea  Brothers  &  Co.'s  Publications — Throat,  Lungs,  Heart. 


FLINT,  AUSTIN,  M.  I)., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  Y. 

A.  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fourth  edition.  In  one 
handsome  royal  12mo.  volume  of  278  pages,  with  14  illustrations.  Cloth,  $1.75. 

This  admirable  little  book  is  too  well  known  to  I  eiated.  We  ourselves  have  used  a  former  edition 
require  any  extended  notice.  That  a  thir«i  and  j  as  a  text-book  in  teaching  the  physical  examina- 
large  edition  has  been  exhausted  in  little  more  tion  of  the  che«t,  and  can  consequently  speak  from 
than  two  years,  is  evidence  that  the  book  is  appre-  |  experience.— Boston  Med.  and  Sur.  Jour., Feb.  11 '80. 


BY  THE  SAME  AUTHOR. 

Physical  Exploration  of  the  Lungs  by  Means  of  Auscultation  and 
Percussion.  Three  lectures  delivered  before  the  Philadelphia  County  Medical  Society,. 
1882-83.    In  one  handsome  small  12mo.  volume  of  83  pages.    Cloth,  $1.00. 

A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.    In  one  handsome  octavo  volume  of  591  pages.    Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.  In  one  handsome  octavo  volume  of  442  pages. 
Cloth,  $3.50.   

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 
Diseases  of  the  Heart.  Second  revised  and  enlarged  edition.  In  one  octavo  volume 
of  550  pages,  with  a  plate.    Cloth,  $4. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.    Cloth,  $1.38. 


BROWNE,  LENNOX,  E.  It.  C.  S.,  E., 

Senior  Physician  to  the  Central  London  Throat  and  Ear  Hospital. 

A  Practical  Guide  to  Diseases  of  the  Throat  and  Nose,  including 
Associated  Affections  of  the  Ear.  With  120  illustration  in  color,  and  200  en- 
gravings on  wood  designed  and  executed  by  the  Author.  New  (second)  and  enlarged 
edition.    In  one  imperial  octavo  volume  of  about  600  pages.    Cloth,  $6.    Just  ready. 

GROSS,  S.  JX,  M.I).,  LL.JD.,  D.C.L.  Oxon.,  LL.JD.  Cantab. 
A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.   In  one 

octavo  volume  of  452  pages,  with  59  illustrations.    Cloth,  $2.7 5. 

COHEN,  J.  SOLIS,  M.  I)., 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  (Esophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.  Preparing. 

SEILEU,  CARL,  M.  D., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.    Second  edition.    In  one  handsome  royal  12mo.  volume 

of  294  pages,  with  77  illustrations.    Cloth,  $1.75. 


It  is  one  of  the  best  of  the  practical  text-books 
on  this  subject  with  which  we  are  acquainted.  The 
present  edition  has  been  increased  in  size,  but  its 
eminently  practical  character  has  been  main- 
tained. Many  new  illustrations  have  also  been 
introduced,  a  case-record  sheet  has  been  added, 


and  there  are  a  valuable  bibliography  and  a  good 
index  of  the  whole.  For  any  one  who  wishes  to 
make  himself  familiar  with  the  practical  manage- 
ment of  cases  of  throat  and  nose  disease,  the  book 
will  be  found  of  great  value. — New  York  Medical 
Journal,  June  9,  1883. 


JP-, 


BROADBENT,  W.  II.,  M.  />.,  F.  R.  C. 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary's  Hospital. 
The  Pulse.  In  one  12mo.  volume.  Preparing.  See  Series  of  Clinical  Manuals,  page  4 


FULLER  ON  DISEASES  OF  THE  LCJNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  $3.50.  • 

BLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  pp.  158.   Cloth,  $1.25. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.  In  1  vol.  8vo.,  416  pp.    Cloth,  $3.00. 


its  Early  and  Reme- 
p.  253.    Cloth,  $2.25. 
LA.    1  vol.  8vo.  of  490 


SMITH  ON  CONSUMPTION; 
diable  Stages.   1  vol.  8vo.,  p 

LA  ROCHE  ON  PNEUMONJ 
pages.    Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.  In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.50. 

JONES'  CLINICAL  OBSERVATIONS  ON  FUNC- 
TIONAL NERVOUS  DISORDERS.  Second  Am- 
erican edition.  In  one  handsome  octavo  volume 
of  340  pages.   Cloth,  $3.25. 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,  etc.  19 


BOSS,  JAMBS,  M.JD.,  F.B.C.P.,  LL.JD., 

Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 

A  Handbook  on  Diseases  of  the  Nervous  System.  In  one  octavo 
volume  of  725  pages,  with  184  illustrations.    Cloth,  $4.50  ;  leather,  $5.50. 

This  admirable*  work  is  intended  for  students  of 
medicine  and  for  such  medical  men  as  have  no  time 
for  lengthy  treatises.  In  the  present  instance  the 
■duty  of  arranging  the  vast  store  of  material  at  the 
disposal  of  the  author,  and  of  abridging  the  de 


scription  of  the  different  aspects  of  nervous  dis- 
eases, has  been  performed  with  singular  skill,  and 
the  result  is  a  concise  and  philosophical  guide  to 


the  department  of  medicine  of  which  it  treats. 
Dr.  Ross  holds  such  a  high  scientific  position  that 
any  writings  which  bear  his  name  are  naturally 
expected  to  have  the  impress  of  a  powerful  intel- 
lect. In  every  part  this  handbook  merits  the 
highest  praise,  and  will  no  doubt  be  found  of  the 
greatest  value  to  the  student  as  well  as  to  the  prac- 
titioner.— Edinburgh  Medical  Journal,  Jan.  1887. 


MITCHELL,  S.  WEIR,  M.  I)., 

Physician  to  Orthopaedic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  Fustem,  Phila.t  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  Women. 

Second  edition.    In  one  12mo.  volume  of  288  pages.  Cloth,  $1.75. 

No  work  in  our  language  develops  or  displays 
more  features  of  that  many-sided  affection,  hys- 


teria, or  gives  clearer  directions  for  its  differed 
tiation,  or  sounder  suggestions  relaiive  to  its 
general  management  and  treatment.  The  book 
is  particularly  valuable  in  that  it  represents  in 
the  main  the  author's  own  clinical  studies,  which 
have  been  so  extensive  and  fruitful  as  to  give  his 


teachings  the  stamp  of  authority  all  over  the 
realm  of  medicine.  The  work(  although  written 
by  a  specialist,  has  no  exclusive  character,  and 
the  general  practitioner  above  all  others  will  fina 
its  perusal  profitable,  since  it  deals  with  diseases 
which  he  frequently  encounters  and  must  essay 
to  treat. — American  Practitioner,  August,  1885. 


HAMILTON,  ALLAN  McLANE,  M.  JD., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackwelVs  Island,  N.  7. 
Nervous  Diseases ;  Their  Description  and  Treatment.    Second  edition,  thoroughly 
In  one  octavo  volume  of  598  pages,  with  72  illustrations.   Cloth,  $4. 

characterized  this  book  as  the  best  of  its  kind  in 


revised  and  rewritten. 


When  the  first  edition  of  this  good  book  appeared 
we  gave  it  our  emphatic  endorsement,  and  the 
present  edition  enhances  our  appreciation  of  the 
book  and  its  author  as  a  safe  guide  to  students  of 
clinical  neurology.  One  of  the  best  and  most 
critical  of  English  neurological  journals,  Brain,  has 


any  language,  which  is  a  handsome  endorsement 
from  an  exalted  source.  The  improvements  in  the 
new  edition,  and  the  additions  to  it,  will  justify  its 
purchase  even  by  those  who  possess  the  old. — 
Alienist  and  Neurologist,  April,  1882. 


TTTKE,  DAJSttEL  HACK,  M.  JD., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  467  pages,  with 
two  colored  plates.    Cloth,  $3.00. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomenathe  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  mOst  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.— New  York  Medical  Journal,  September  6, 1884. 


the  general  practitioner  in  guiding  him  to  a  diag- 
nosis and  indicating  the  treatment,  especially  in 
many  obscure  and  doubtful  cases  of  mental  dis- 
ease. To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  make  it  a  desirable  addition  to  every  library. 
— American  Psychological  Journal,  July,  1884. 


CLOUSTOW,  THOMAS  S.,  M.  JD.,  F.  JR.  C.  P.,  L.  H.  C.  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  volume  of  541 
pages,  with  eight  lithographic  plates,  four  of  which  are  beautifully  colored.    Cloth,  $4. 

The  practitioner  as  well  as  the  student  will  ac- 
cept the  plain,  practical  teaching  of  the  author  as  a 
forward  step  in  the  literature  of  insanity.  It  is 
refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  giving  the  bed- 
side notes  upon  which  his  experience  has  been 
founded  and  his  mature  judgment  established. 
Such  clinical  observations  cannot  but  be  useful  to 

Jg^"Dr.  Folsom's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
108  pages.    Cloth,  $1.50.   

SAVAGE,  GEOBGE  H.,  31.  JD., 

Lecturer  on  Mental  Diseases  at  Guy's  Hospital,  London. 

Insanity  and  Allied  Neuroses,  Practical  and  Clinical.  In  one  12mo.  vol. 
of  551  pages,  with  18  illus.    Cloth,  $2.00.    See  Series  of  Clinical  Manuals,  page  4. 

PL A  YE AIM,  W.  S.,  M.  D.,  F.  B.  C.  P. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.  In 

one  handsome  small  12rao.  volume  of  97  pages.    Cloth,  $1.00. 

Blandford  on  Insanity  and  its  Treatment:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of.  Insane  Patients.   In  one  very  handsome  octavo  volume. 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


ASHHVRST,  JOHN,  Jr.,  M.  D., 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

The  Principles  and  Practice  of  Surgery.  New  (fourth)  edition,  enlarged 
and  revised.  In  one  large  and  handsome  octavo  volume  of  1114  pages,  with  597  illustra- 
tions.   Cloth,  $6  ;  leather,  $7  ;  half  Kussia,  $7.50. 


As  with  Erichsen  so  with  Ashhurst,  its  position 
in  professional  favor  is  established,  and  one  has 
now  but  to  notice  the  changes,  if  any,  in  theory 
and  practice,  that  are  apparent  in  the  present 
as  compared  with  the  preceding  edition,  published 
three  years  ago.  The  work  has  been  brought  well 
up  to  date,  and  is  larger  and  better  illustrated  than 
before,  and  its  author  may  rest  assured  that  it  will 
certainly  have  a  "continuance  of  the  favor  with 
which  it  has  hpretofore  been  received."—  The 
American  Journal  of  the  Medical  Sciences,  Jan.  1886. 


Every  advance  in  surgery  worth  notice,  chroni- 
cled in  recent  literature,  has  been  suitably  recog- 
nized and  noted  in  its  proper  place.  Suffice  it  to 
say,  we  regard  Ashhurst's  Surgery,  as  now  pre- 
sented in  the  fourth  edition,  as  the  best  single 
volume  on  surgery  published  in  the  English  lan- 
guage, valuable  alike  to  the  student  and  the  prac- 
titioner, to  the  one  as  a  text-book,  to  the  other  as 
a  manual  of  practical  surgery.  With  pleasure  we 
give  this  volume  our  endorsement  in  full.— New 
Orleans  Medical  and  Surgical  Journal,  Jan.,  1886. 


GROSS,  S.  Ih,  M.  D.,  LL.  D.,  T>.  C.  L.  Oxon.,  LL.  7X 

Cantab., 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery :  Pathological,  Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.    In  two  large  and  beautifully- 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  $15 ;  half  Kussia,  raised  bands,  $16. 

His  System  of  Surgery,  which,  since  its  first  edi- 
tion in  1859,  has  been  a  standard  work  in  this 


Dr.  Gross'  Si/stem  of  Surqery  has  long  been  the 
standard  work  on  that  subject  for  students  and 
practitioners. — London  Lancet,  May  10,  1884. 

The  work  as  a  whole  needs  no  commendation. 
Many  years  ago  it  earned  for  itself  the  enviable 
reputation  of  the  leading  American  work  on  sur- 
gery, and  it  is  still  capable  of  maintaining  that 
standard.  A  considerable  amount  of  new  material 
has  been  introduced,  and  altogether  the  distin- 

fuished  author  has  reason  to  be  satisfied  that  he 
as  placed  the  work  fully  abreast  of  the  state  of 
our  knowledge. — Med.  Record,  Nov.  18, 1882. 


country  as  well  as  in  America,  in  "the  whole 
domain  of  surgery,"  tells  how  earnest  and  labori- 
ous and  wise  a  surgeon  he  was.  how  thoroughly 
he  appreciated  the  work  done  by  men  in  other 
countries,  and  how  much  he  contributed  to  pro- 
mote the  science  and  practice  of  surgery  in  his 
own.  There  has  been  no  man  to  whom  America 
is  so  much  indebted  in  this  respect  as  the  Nestor 
of  surgery. — British  Medical  Journal,  May  10,  1884. 


DRUITT,  ROBERT,  M.  R.  C.  S.,  etc. 

Manual  of  Modern  Surgery.  Twelfth  edition,  thoroughly  revised  by  Stan- 
ley Boyd,  M.  B.,  B.  S.,  F.  R  C.  S.  In  one  8vo.  volume  of  965  pages,  with  373  illustra- 
tions.   Cloth,  $4 ;  leather,  $5. 

FROM  THE  EDITOR'S  PREFACE  TO  THE  TWELFTH  EDITION. 

Few  works  have  been  more  widely  known  and  appreciated  than  Druitt's  "  Surgery." 
In  England  I  am  informed  that  50,000  copies  have  been  sold,  whilst  in  America  it  has 
been  so  highly  appreciated  that  a  copy  was  issued  by  the  Government  to  each  surgeon 
serving  in  the  Federal  Army  during  the  great  Civil  War.  The  twelfth  edition  differs 
much  from  the  eleventh;  scarcely  a  paragraph  of  the  latter  remains  unaltered.  In  spite 
of  my  utmost  endeavors  to  compress,  the  book  has  increased  considerably  in  size.  This 
is  due  to  many  causes,  especially  to  the  greatly  increased  range  of  subjects  with  which  I 
have  had  to  deal,  to  the  replacement  of  many  old  illustrations  by  a  number  of  consider- 
ably larger  ones,  and  to  the  addition  of  a  copious  index. 


GIBJSTEY,  V.  P.,  M.  D., 

Surgeon  to  the  Orthopaedic  Hospital,  New  York,  etc. 
Orthopedic  Surgery.  For  the  use  of  Practitioners  and  Students.  In  one  hand- 
some octavo  volume,  profusely  illustrated.  Preparing. 


ROBERTS,  JOEEJST  B.,  A.  31.,  M.  D., 

Lecturer  on  Anatomy  and  on  Operative  Surgery  at  the  Philadelphia  School  of  Anatomy. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students- 
and  Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  about 
500  pages,  with  many  illustrations.  Preparing. 


BELLAMY,  EDWARD,  F.  R.  C.  S., 

Surgeon  and  Lecturer  on  Surgery  at  Charing  Cross  Hospital,  London. 
Operative  Surgery.    Shortly.    See  Student^  Series  of  Manuals,  page  4. 

BALL,  CHARLES  B.,  M.  Ch.,  Dub.,  F.  R.  C.  S.  E., 

Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital,  Dublin. 

Diseases  of  the  Rectum  and  Anus.    In  one  12mo.  volume  of  550  pages. 

Preparing.    See  Series  of  Clinical  Manuals,  page  4. 


MILLER'S  PRACTICE  OF  SURGERY.  Fourth 
and  revised  American  from  the  last  Edinburgh 
edition.  In  one  large  8vo.  vol.  of  682  pages,  with 
364  illustrations.   Cloth,  $3.75. 


MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 
one  8vo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  $3.75. 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


21 


EUICHSE2T,  JOHN  E.,  F.  R.  S.,  F.  R.  C.  S., 

Professor  of  Surgery  in  University  College,  London,  etc. 
The  Science  and  Art  of  Surgery;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.    From  the  eighth  and  enlarged  English  edition.    In  two  large  and 
beautiful  octavo   volumes  of  2316   pages,   illustrated  with  984  engravings  on  wood. 
Cloth,  $9;  leather,  raised  bands,  $11  ;  half  Russia,  raised  bands,  $12. 

In  noticing  the  eighth  edition  of  this  well-  I  years  and  maintaining  during  that  period  a  re- 
known  work,  it  would  appear  superfluous  to  say  putation  as  a  leading  work  on  surgery,  there  is  not 
more  than  that  it  has,  like  its  predecessors,  been  muoh  to  be  said  in  the  way  of  comment  or  criti- 
brought  fully  up  to  the  times,  and  is  in  conse-  cism.  That  it  still  holds  its  own  goes  without  say- 
quence  one  of  the  best  treatises  upon  surgery  that  ing.  The  author  infuses  into  it  his  large  experi- 
has  ever  been  penned  by  one  man.  We  nave  al-  enee  and  ripe  judgment.  Wedded  to  no  school, 
ways  regarded  "The  Science  and  Art  of  Surgery"  committed  to  no  theory,  biassed  by  no  hobby,  he 
as  one  of  the  best  surgical  text-books  iu  the  imparts  an  honest  personality  in  his  observations. 
English  language,  and  this  eighth  edition  only  and  his  teachings  are  the  rulings  of  an  impartial 
confirms  our  previous  opinion.  We  take  great  judge.  Such  men  are  always  safe  guides,  and  their 
pleasure  in  cordially  commending  it  to  our  read-  works  stand  the  tests  of  time  and  experience, 
ers. —  The  Medical  News,  April  11, 1£85.  Such  an  author  is  Erichsen,  and  such  a  work  is  his 

After  being  before  the  profession  for  thirty  |  Surgery. — Medical  Record,  Feb.  21,  1885. 


BRYANT,  THOMAS,  F.  R.  C.  S., 

Surgeon  and  Lecturer  on  Surgery  at  Gity's  Hospital,  London. 
The  Practice  of  Surgery.    Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.    In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.    Cloth,  $6.50;  leather,  $7.50;  half  Russia,  $8.00. 

The  fourth  edition  of  this  work  is  fully  abreast :  books  for  the  medical  student.  Almost  every 
of  the  times.    The  author  handles  his  subjects   topic  in  surgery  is  presented  in  such  a  form  as  to 


with  that  degree  of  judgment  and  skill  wnich  is 
attained  by  years  of  patient  toil  and  varied  ex- 
perience. The  present  edition  is  a  thorough  re- 
vision of  those  which  preceded  it,  with  much  new 
matter  added.  His  diction  is  so  graceful  and 
logical,  and  his  explanations  are  so  lucid,  as  to 
place  the  work  among  the  highest  order  of  text- 


enable  the  busy  practitioner  to  review  any  subject 
in  every-day  practice  in  a  short  time.  Nb  time  is 
lost  with  useless  theories  or  superfluous  verbiage. 
In  short,  the  work  is  eminently  ciear,  logical  and 
practical. — Chicago  Medical  Journal  and  Examiner, 
April,  1886. 


By  the  same  Author. 
Diseases  of  the  Breast.  In  one  12mo.  volume.  Preparing.  See  Series  of  Clinical 
Manuals,  page  4. 

TREVES,  FREDERICK,  F.  R.  C.  S., 

Hunterian  Professor  at  the  Royal  College  of  Surgeons  of  England. 
A  Manual  of  Surgery.    In  Treatises  by  Various'  Authors.    In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.    Price  per  volume,  cloth,  $2.  See 
Students'  Series  of  Manuals,  page  4. 


We  have  here  the  opinions  of  thirty-three 
authors,  in  an  encyclopedic  form  for  easy  and 
ready  reference.  The  three  volumes  embrace 
every  variety  of  surgical  affections  likely  to  be 
met  with,  the  paragraphs  are  short  and  pithy,  and 
the  salient  points  and  the  beginnings  of  new  sub- 
jects are  always  printed  in  extra-heavy  type,  so 
that  a  person  may  find  whatever  information  he 
may  be  in  need  of  at  a  moment's  glance. — Cin- 
cinnati Lancet-Clinic,  August  21, 1886. 

The  hand  of  Mr.  Treves  is  evident  throughout 


in  the  choice,  arrangement  and  logical  sequence  of 
the  subjects.  Every  topic,  as  far  as  observed,  is 
treated  with  a  fulness  of  essential  detail,  which  is 
somewhat  surprising.  Another  characteristic  of  the 
work  is  the  well-nigh  universal  acceptance  of  mod- 
ern and  progressive  views  of  pathology  and  treat- 
ment. The  entire  work  is  conceived  and  executed 
in  a  scientific  spirit.  It  contains  the  bone  and  mar- 
row of  modern  surgery.— A nnals  of  Surgery,  Oct. 
1886. 


BTJTLIN,  HEJSRY  T.,  F.  R.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew'1 s  Hospital,  London. 
Diseases   of  the  Tongue.     In  one  12mo.  volume  of  456  pages,  with  8  colored 
plates  and  3  woodcuts.    Cloth,  $3.50.    See  Series  of  Clinical  Manuals,  page  4. 

The  language  of  the  text  is  clear  and  concise,    veniently  scattered  through  general  works  on  sur- 
The  author  has  aimed  to  state  facts  rather  than  to   gery  and  the  practice  of  medicine.   The  physician 
express  opinions,  and  has  compressed  within  the   and  surgeon  will  appreciate  its  value  as  an  aid  and 
compass  of  this  small  volume  the  pathology,  etiol-  j  guide.— Physician  and  Surgeon,  Sept.  1886. 
ogy,  etc.,  of  diseases  of  the  tongue  that  are  incon-  | 

TREVES,  FREDERICK,  F.  R.  C.  8., 

Surgeon  to  and  Lecturer  on  Surgery  at  the  London  Hospital. 

Intestinal  Obstruction.  In  one  pocket-size  12mo.  volume  of  522  pages,  with  60 
illustrations.  Limp  cloth,  blue  edges,  $2.00.    See  Series  of  Clinical  Manuals,  page  4. 

A  standard  work  on  a  subject  that  has  not  been  |  justice  to  the  author  in  a  few  paragraphs.  Intes- 
so  comprehensively  treated  by  any  contemporary  i  tinal  Obstruction  is  a  work  that  will  Drove  of 
English  writer.  Its  completeness  renders  a  full  ,  equal  value  to  the  practitioner,  the  student,  the 
review  difficult,  since  every  chapter  deserves  mi-  pathologist,  the  physician  and  the  operating  sur- 
nute  attention,  and  it  is  impossible  to  do  thorough   geon.— British  Medical  Journal,  Jan.  31, 1885. 


GOULD,  A.  JPEARCE,  M.  S.,  M.  B.,  F.  R.  C.  8., 

Assistant  Surgeon  to  Middlesex  Hospital. 

Elements  of  Surgical  Diagnosis.    In  one  pocket-size  12mo.  volume  of  589 
Cloth,  $2.00.    See  Students'  Series  of  Manuals,  page  4. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.   Cloth,  $3.75. 


SKEY'S  OPERATIVE  SURGERY.  In  one  vol.  8v... 
of  661  pages,  with  81  woodcuts.   Cloth,  $3.25. 


22     Lea  Brothers  &  Co.'s  Publications — Surgery,  Frac,  Disloc. 


HOLMES,  TIMOTHY,  M.  A., 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.   IN  TKEATISES  BY 

VABIOUS  AUTHORS.  American  edition,  thoroughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  and  very  handsome  imperial  octavo  volumes  containing  3137  double- 
columned  pages,  with  979  illustrations  on  wood  and  13  lithographic  plates,  beautifully 
colored.    Price  per  set,  cloth,  $18.00;  leather,  $21.00;  half  Russia,  $22.50.    Sold  only  by 


HAMILTON,  FRANK  II.,  M.  JO.,  LL.  2>., 

Surgeon  to  BeUevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Seventh  edition 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages,  with  379  illustrations.    Cloth,  $5.50:  leather,  $6.50;  very  handsome  half  Russia, 


open  back,  $7.00, 

It  is  about  twenty-five  years  ago  since  the  first 
edition  of  this  great  work  appeared.  The  edition 
now  issued  is  the  seventh,  and  this  fact  alone  is 
enough  to  testify  to  the  excellence  of  it  in  all  par- 
ticulars. Books  upon  special  subjects  do  not 
usually  command  extended  sale,  bat  this  one  is 
without  a  rival  in  any  language.  It  is  essentially 
a  practical  treatise,  and  it  gathers  within  its  covers 
almost  everything  valuable  that  nas  been  written 
about  fractures  and  dislocations.  The  principles 
and  methods  of  treatment  are  very  fully  given. 
The  book  is  so  well  known  that  it  does  not  require 


any  lengthened  review.  We  can  only  say  that  it 
is  still  unapproached  as  a  treatise,  and  that  it  is  a 
proof  of  the  zeal  and  industry  and  great  abilitv  of 
its  distinguished  author.—  The  Dublin  Journal  of 
Medical  Science,  Feb.  1886. 

His  famous  treatise  on  Fractures  and  Disloca- 
tions, published  first  in  1860,  is  justly  regarded  as 
the  best  book  on  that  subject  in  existence.  It  has 
now  run  through  seven  editions,  and  has  been 
translated  into  French  and  German.— Medical 
Record,  Aug.  14,  1886. 


SMITH,  STEPHEN,  M.  I)., 

Professor  of  Clinical  Surgery  in  the  University  of  the  City  of  New  York. 

The  Principles  and  Practice  of  Operative  Surgery.  New  (second)  and 
thoroughly  revised  edition.  In  one  very  handsome  octavo  volume  of  892  pages,  with 
1005  illustrations.    Cloth,  $4  00;  leather,  $5.00.    Just  ready. 

plete  works  in  the  English  language,  and  is  a  fit 
companion  to  Malgaigne's  magnificent  treatise. 
The  woodcuts  are  good,  and  are  very  numerous. 
The  descriptions  of  operative  procedures  are  plain, 
and  the  opinions  expressed  are  conservative  and 
judicious.  The  work  reflects  great  credit  upon  the 
author  and  upon  American  surgical  literature. — 
The  American  Journal  of  the  Medical  Sciences,  April, 
1887. 


This  work  is  too  well  and  too  favorably  known  to 
require  any  words  of  commendation,  and  its  mer- 
its effectually  protect  it  from  adverse  criticism. 
It  is  a  treatise  upon  the  principles  as  well  as  the 
practice  of  mechanical  surgery.  %The  subject  mat- 
ter is  brought  down  to  the  very  latest  period,  hence 
we  shall  find  the  work  to  be  a  faithful  exponent 
of  the  art  of  surgery  as  practised  now.  Stepheu 
Smith's  Operative  Surgery  is  one  of  the  most  com- 


STIMSON,  LEWIS  A.,  B.  A.,  M.  I)., 

Professor  of  Pathological  Anatomy  at  the  University  of  the  City  of  New  York,  Surgeon  and  Curator 
to  Bellevue  Hospital,,  Surgeon  to  the  Presbyterian  Hospital,  New  York,  etc. 

A  Manual  of  Operative  Surgery.  New  (second)  edition.  In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.    Cloth,  $2.50. 

There  is  always  room  for  a  good  book,  so  that 
while  many  works  on  operative  surgery  must  be 


considered  superfluous,  that  of  Dr.  Stimson  has 
held  its  own.  The  author  knows  the  difficult  art 
of  condensation.  Thus  the  manual  serves  as  a 
work  of  reference,  and  at  the  same  time  as  a 
handy  guide  It  teaches  what  it  professes,  the 
steps  of  operations.  In  this  edition  Dr.  Stimson 
has  sought  to  indicate  the  changes  that  have  been 


effected  in  operative  methods  and  procedures  by 
the  antiseptic  system,  and  has  added  an  account 
of  many  new  operations  and  variations  in  the 
steps  of  older  operations.  We  do  not  desire  to 
extol  this  manual  above  many  excellent  standard 
British  publications  of  the  same  class,  still  we  be- 
lieve that  it  contains  much  that  is  worthy  of  imi- 
tation.— British  Medical  Journal,  Jan.  22,  1887. 


By  the  same  Author. 
A  Practical  Treatise  on  Fractures  and  Dislocations.  Volume  L,  Frac- 
tures.   In  one  very  handsome  octavo  volume  of  598  pages,  with  360  beautiful  illustrations. 
Cloth,  $4.75 ;  leather,  $5.75. '  Volume  II.,  Dislocations.  Containing  500  pages,  with  200 
illustrations,  is  in  press. 


The  author  has  given  to  the  medical  profession 
in  this  treatise  on  fractures  what  is  likely  to  be- 
come a  standard  work  on  the  subject.  Itis  certainly 
not  surpassed  by  any  work  written  in  the  English, 
or,  for  that  matter,  any  other  language.  The  au- 
thor tells  us  in  a  short,  concise  and  comprehensive 
manner,  all  that  is  known  about  his  subject.  There 
is  nothing  scanty  or  superficial  about  it,  as  in  most 
other  treatises ;  on  the  contrary,  everything  is  thor- 


ough. The  chapters  on  repair  of  fractures  and  their 
treatment  show  him  not  only  to  be  a  profound  stu- 
dent, but  likewise  a  practical  surgeon  and  patholo- 
gist. His  mode  of  treatment  of  the  different  fract- 
ures is  eminently  sound  and  practical.  We  consider 
this  work  one  of  the  best  on  fractures  ;  and  it  will 
be  welcomed  not  onlv  as  a  text-book,  but  also  by 
the  surgeon  in  full  practice. — N.  O.  Medical  and 
Surgical  Journal,  March,  1883. 


MARSH,  HO  WARD,  F.  R.  C.  S., 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 
Diseases  of  the  Joints.    In  one  12mo.  volume  of  468  pages,  with  64  woodcuts 
and  a  colored  plate.    Cloth,  $2.00.    See  Series  of  Clinical  Manuals,  page  4. 

PICK,  T.  PICKERING,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.  In  one  12mo.  volume  of  530  pages,  with  93 
illustrations.    Limp  cloth,  2.00.    See  Series  of  Clinical  Manuals,  page  4. 


Lea  Brothers  &  Co.'s  Publications — Otol.,  Ophthal.  23 


BURNETT,  CHARLES  II.,  A.  M.,  M.  I)., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic ;  President  of  the  American  Otological  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  New  (second)  edition.  In  one  handsome 
octavo  volume  of  580  pages,  with  107  illustrations.  Cloth,  $4.00 ;  leather,  $5.00. 

We  note  with  pleasure  the  appearance  of  a  second  j  carried  out,  and  much  new  matter  added.  Dr. 
edition  of  this  valuable  work.  When  it  first  came  Burnett's  work  must  be  regarded  as  a  very  valua- 
out  it  was  accepted  by  the  profession  as  one  of  ble  contribution  to  aural  surgery,  not  only  on 
the  standard  works  on  modern  aural  surgery  in  account  of  its  comprehensiveness,  but  because  it 
the  English  language;  and  in  his  second  edition  contains  the  results  of  the  careful  personal  observa- 
Dr.  Burnett  has  fully  maintained  his  reputation,  tion  and  experience  of  this  eminent  aural  surgeon, 
for  the  book  is  replete  with  valuable  information  —London  Lancet,  Feb.  21,  1885. 
and  suggestions.   The  revision  has  been  carefully 

POLITZER,  ADAM, 

Imperial  Royal  Prof,  of  Aural  Therap.  in  the  Univ.  oj  Vienna. 

A  Text-Book  of  the  Ear  and  its  Diseases.  Translated,  at  the  Author's  re- 
quest, by  James  Patterson  Cassells,  M.  D.,  M.  R.  C.  S.  In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.    Cloth,  $5.50. 

The  work  itself  we  do  not  hesitate  to  pronounce  section,  and  this  again  by  the  pathological  physi- 
the  best  upon  the  subject  of  aural  diseases  which  ology,  an  arrangement  which  serves  to  keep  up  the 
has  ever  appeared,  systematic  without  being  too  interest  of  the  student  by  showing  the  direct  ap- 
diffuse  on  obsolete  subjects,  and  eminently  prac-  plication  of  what  has  preceded  to  the  study  of  dis- 
tical  in  every  sense.  The  anatomical  descriptions  I  ease.  The  whole  work  can  be  recommended  as  a 
of  each  separate  division  of  the  ear  are  admirable,  \  reliable  guide  to  the  student,  and  an  efficient  aid 
and  profusely  illustrated  by  woodcuts.  They  are  j  to  the  practitioner  in  his  treatment. — Boston  Med~ 
followed  immediately  by  the  physiology  of  the  |  ical  and  Surgical  Journal,  June  7, 1883. 

JJJLER,  HEJSRY  E.,  F.  R.  C.  S., 

Senior  Ass't  Surgeon,  Roval  Westminster  Ophthalmic  Hosp. ;  Me  Clinical  Ass't,  Moorfields,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handsome 
octavo  volume  of  460  pages,  with  125  woodcuts,  27  colored  plates,  selections  from  the 
Test-types  of  Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test.  Cloth,  $4.50 ; 
leather,  $5.50. 

This  work  is  distinguished  by  the  great  num-  j  and  typical  illustrations  of  all  important  eye 
ber  of  colored  plates  which  appear  in  it  for  illus-  affections,  placed  in  juxtaposition,  so  as  to  be 
trating  various  pathological  conditions.  They  are  i  grasped  at  a  glance.  Beyond  a  doubt  it  is  the 
very  beautiful  in  appearance,  and  have  been  best  illustrated  handbook  of  ophthalmic  science 
executed  with  great  care  as  to  accuracy.  An  ex-  which  has  ever  appeared.  Then,  what  is  still 
amination  of  the  work  shows  it  to  be  one  of  high  better,  these  illustrations  are  nearly  all  original, 
standing,  one  that  will  be  regarded  as  an  authority  We  have  examined  this  entire  work  with  great 
among  ophthalmologists.  The  treatment  recom-  j  care,  and  it  represents  the  commonly  accepted 
mended  is  such  as  the  author  has  learned  from  !  views  of  advanced  ophthalmologists.  We  can  most 
actual  experience  to  be  the  best.— Cincinnati  Medi-  j  heartily  commend  this  book  to  all  medical  stu- 
cal  News,  Dec.  1884.  dents,   practitioners   and    specialists.  —  Detroit 

It  presents  to  the  student  concise  descriptions  I  Lancet,  Jan.  1885. 

NORRIS,  WM.  F.,  M.  D.,  and  OLIVER,  CJETAS.  A.,  M.  D. 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 

A  Text-Book  of  Ophthalmology.  In  one  octavo  volume  of  about  500  pages, 
with  illustrations.  Preparing. 

CARTER,  R.  BRTJDEJSTELL,  &  FROST,  W.  ADAMS, 

F.  R.  C.  S.,  F.  R.  C.  S., 

Ophthalmic  Surgeon  to  and  Lecturer  on  Oph-  Assistant  Ophthalmic  Surgeon  to  and  Joint 

thalmic   Surgery  at   St.  George's  Hospital,  Lecturer  on  Ophthalmic  Surgery  at  St. 

London.  George's  Hospital,  London. 

Ophthalmic  Surgery.  In  one  12mo.  volume  of  about  400  pages.  Preparing. 
See  Series  of  Clinical  Manuals,  page  4. 

WELLS,  J.  SOELBERG,  F.  R.  C.  S., 

Professor  of  Ophthalmology  in  Kinq's  College  Hospital,  London,  etc. 

A  Treatise  on  Diseases  of  the  Eye.  New  (fifth)  American  from  the  third 
London  edition.    In  one  large  octavo  volume.  Preparing. 

NETTLESHIF,  EDWARD,  F.  R.  C.  S., 

Ophthalmic  Surg,  and  Lect.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  New  (third)  edition,  thor- 
oughly revised.  With  a  chapter  on  the  Detection  of  Color-Blindness,  by  William 
Thomson,  M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College.  In  one 
royal  12mo.  volume  of  about  450  pages,  with  about  150  illustrations.    Cloth,  $2.  Shortly. 

BROWNE,  EDGAR  A., 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary  and  to  the  Dispensary  for  Skin  Diseases. 
How  to  Use  the  Ophthalmoscope.    Being  Elementary  Instructions  in  Oph- 
thalmoscopy, arranged  for  the  use  of  Students.    In  one  small  royal  12mo.  volume  of  116 
pages,  with  35  illustrations.    Cloth,  $1.00. 

LAURENCE  AND  MOON'S  HANDY  BOOK  OF  I  LAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac-      AND  EYELIDS:  Their  Immediate  and  RemotA 
titioners.   Second  edition.    In  one  octavo  vol-      Effects.   8  vo.,  404  pp.,  92  illus.   Cloth,  $3.60. 
ume  of  227  pages,  with  65  illust.   Cloth,  $2.75.  i 


24    Lea  Brothers  &  Co.'s  Publications — TJrin.  Dis.,  Dentistry,  etc. 


ROBERTS,  WILLIAM,  M.  I)., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  the  fourth  London  edition.  In  one  hand- 
some octavo  volume  of  609  pages,  with  81  illustrations.    Cloth,  $3.50. 

The  previous  editions  of  this  book  have  made  it  The  peculiar  value  and  finish  of  the  book  are  in 
bo  familiar  to  and  so  highly  esteemed  by  the  med-  a  measure  derived  from  its  resolute  maintenance 
ical  public,  that  little  more  is  necessary  than  a  of  a  clinical  and  practical  character.  It  is  an  un- 
mere  announcement  of  the  appearance  of  this,  rivalled  exposition  of  everything  which  relates 
their  successor.  But  it  is  pleasant  to  be  able  to  directly  or  indirectly  to  the  diagnosis,  prognosis 
say  that,  good  as  those  were,  this  is  still  better,  and  treatment  of  urinary  diseases,  and  possesses 
In  fact,  we  think  it  may  be  said  to  be  the  best  book  a  completeness  not  found  elsewhere  in  our  lan- 
in  print  on  the  subject  of  which  it  treats. —  The  guage  in  its  account  of  the  different  affections. — 
American  Journal  of  the  Medical  Sciences. — Jan.  1886.    The  Manchester  Medical  Chronicle,  July,  1885. 


FURDY,  CHARLES  W.,  M.  D. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys.  In  one  octavo 

volume  of  288  pages,  with  illustrations.    Cloth,  $2.  Just  ready. 

short  space  the  theories,  facts  and  treatments,  and 


The  object  of  this  work  is  to  "furnish  a  system- 
atic, practical  and  concise  description  of  the 
pathology  and  treatment  of  the  chief  organic 
diseases  of  the  kidney  associated  with  albuminu- 
ria, which  shall  represent  the  most  recent  ad- 
vances in  our  knowledge  on  these  subjects  ; "  and 
this  definition  of  the  object  is  a  fair  description  of 
the  book.   The  work  is  a  useful  one,  giving  in  a 


going  more  fully  into  their  later  developments. 
On  treatment  the  writer  is  particularly  strong, 
steering  clear  of  generalities,  and  seldom  omit- 
ting, what  text-books  usually  do,  the  unimportant 
items  which  are  all  important  to  the  general  prac- 
titioner.—  The  Manchester  Medical  Chronicle,  Oct., 
1886. 


MORRIS,  ME  WRY,  M.  B.,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Kidney.  In  one  12mo.  volume  of  554  pages,  with  40 
woodcuts,  and  6  colored  plates.  Limp  cloth,  $2.25.    See  Series  of  Clinical  Manuals,  page  4. 

he  took  in  hand.  It  is  a  full  and  trustworthy 
book  of  reference,  both  for  students  and  prac- 
titioners in  search  of  guidance.  The  illustrations 
in  the  text  and  the  chromo-lithographs  are  beau- 


In  this  manual  we  have  a  distinct  addition  to 
surgical  literature,  which  gives  information  not 
elsewhere  to  be  met  with  in  a  single  work.  Such 
a  book  was  distinctly  required,  and  Mr.  Morris 
has  very  diligently  and  ably  performed  the  task 


tifully  executed. —  The  London  Lancet,Feb.  26, 


LUCAS,  CLEMENT,  M.  B.,  B.  S.,  F.  R.  C.  S., 

Senior  Assistant  Surgeon  to  Guy's  Hospital,  London. 
Diseases  of  the  Urethra.     In  one  12mo.  volume.    Preparing.    See  Series 

of  Clinical  Manuals,  page  4.   

THOMPSON,  SIR  HENRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.    In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.    Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulse.    From  the  third  English  edition.    In  one  octavo  volume  of  359 

pages,  with  47  cuts  and  3  plates.    Cloth,  $3.50. 

THE  AMERICAN  SYSTEM  OF  DENTISTRY. 

In  Treatises  by  Various  Authors.  Edited  by  Wilbur  F.  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  con- 
taining 3180  pages,  with  1863  illustrations  and  9  full  page  plates.  Per  volume,  cloth,  $6 ; 
leather,  $7  ;  half  Morocco,  gilt  top,  $8.  The  complete  work  is  now  ready.  For  sale  by 
subscription  only. 


As  an  encyclopaedia  of  Dentistry  it  has  no  su- 

f>erior.  It  should  form  a  part  of  every  dentist's 
ibrary,  as  the  information  it  contains  is  of  the 

Greatest  value  to  all  engaged  in  the  practice  of 
entistry. — American  Journal  of  Dental  Science, 
September,  1886. 

A  grand  system,  big  enough  and  good  enough 
and  handsome  enough  for  a  monument  (which 


doubtless  it  is),  to  mark  an  epoch  in  the  history  of 
dentistry.  Dentists  will  be  satisfied  with  it  and 
proud  of  it — they  must.  It  is  sure  to  be  precisely 
what  the  student  needs  to  put  him  and  keep  him 
in  the  right  track,  while  the  profession  at  large 
will  receive  incalculable  benefit  from  it. — Odonto- 
graphy Journal,  Jan.  1887. 


COLEMAN,  A.,  L.  R.  C.  F.,  F.  R.  C.  S.,  Exam.  L.  D.  S., 

Senior  Dent.  Surg,  and  Led.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hosp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellwagen,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  at  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.    Cloth,  $3.25. 

ESMARCH,  Dr.  FRIED  RICH, 

Professor  of  Surgery  at  the  University  of  Kiel,  etc. 

Early  Aid  in  injuries  and  Accidents.  Five  Ambulance  Lectures.  Trans- 
lated by  H.  E.  H.  Princess  Christian.  In  one  handsome  small  12mo.  volume  of  109 
pages,  with  24  illustrations.    Cloth,  75  cents. 

BASHAM   ON  RENAL  DISEASES :  A  Clinical  I  one  12mo.  vol.  of  304  pages,  with  21  illustrations. 
Guide  to  their  Diagnosis  and  Treatment.   In  |  Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Venereal,  Impotence. 


25 


GROSS,  SAMUEL  W.,  A.  31.,  31.  T>.,  LL.  JO., 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College  of  Phila. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  New  (third)  edition,  thoroughly  revised.  In  one  very 
handsome  octavo  volume  of  163  pages,  with  16  illustrations.  Cloth,  $1.50.  Just  ready. 
We  must  congratulate  the  author  that  another  |  that  it  has  been  translated  into  Russian  may  indi- 


edition  has  been  made  necessary.  The  tone  of 
the  book  is  healthy,  and  a  cheerful  prognosis  is 
given  of  many  of  the  affections  of  which  it  treats. 
We  feel  confident  that  the  book  will  continue  to 
sell  on  its  merits. — A\  Y.  Med.  Journal,  June  18, 1887. 

It  must  be  gratifying  to  both  author  and  pub- 
lishers that  large  first  and  second  editions  of  this 
little  work  were  so  soon  exhausted,  while  the  fact 


cate  that  it  filled  a  void  even  in  foreign  literature. 
His  is  a  careful  and  physiological  study  of  the 
sexual  act,  so  far  as  concerns  the  male,  and  all 
his  conclusions  are  scientifically  reached.  The 
book  has  a  place  by  itself  in  our  literature,  and 
furnishes  a  large  fund  of  information  concerning 
important  matters  that  are  too  often  passed  over 
in  silence.— The  Medical  Press,  June,  1887. 


BUMSTFAJO,  F.  J.,  and  TAYLOR,  R.  W., 

M.  JD.,  LL.  JO.,  A.  M.,  31.  JX, 

Late  Professor  of  Venereal  Diseases  Sttrgeon  to  Chanty  Hospital,  New  York,  Prof,  of 

at  the   College  of  Physicians  and  Venereal  and  Skin  Diseases  in  the  University  of 

Surgeons,  New  York,  etc.  Vermont,  Pres.  of  the  Am.  Dermatol  ogical  Ass'n. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  Fifth  edition,  revised  and  largely  re- 
written, by  Dr.  Taylor.  In  one  large  and  handsome  octavo  volume  of  898  pages  with 
139  illustrations,  and  thirteen  chromo-lithographic  figures.  Cloth,  $4.75  ;  leather,  $5.75  ; 
very  handsome  half  Russia,  $6.25. 

It  is  a  splendid  record  of  honest  labor,  wide 
research,  just  comparison,  careful  scrutiny  and 
original  experience,  which  will  always  be  held  as 
a  high  credit  to  American  medical  literature.  This 
is  not  only  the  best  work  in  the  English  language 
upon  the  subjects  of  which  it  treats,  but  also  one 
wnich  has  no  equa.  in  other  tongues  for  its  clear, 
comprehensive  and  practical  handling  of  its 
themes.— Am.  Jour,  of  the  Med.  Sciences,  Jan,  1884. 

It  is  certainly  the  best  single  treatise  on  vene- 
real in  our  own,  and  probably  the  best  in  any  lan- 
guage.— Boston  Med.  and  Surg.  Journal,  April  3, 1884. 

The  character  of  this  standard  work  is  so  well 


known  that  it  would  be  superfluous  here  to  pass  in 
review  its  general  or  special  points  of  excellence. 
The  verdict  of  the  profession  has  been  passed;  it 
has  been  accepted  as  the  most  thorough  and  com- 
plete exposition  of  the  pathology  and  treatment  of 
venereal  diseases  in  the  language.  Admirable  as  a 
model  of  clear  description,  an  exponent  of  sound 
pathological  doctrine,  and  a  guide  for  rational  and 
successful  treatment,  it  is  an  ornament  to  the  medi- 
cal literature  of  this  country.  The  additions  made 
to  the  present  edition  are  eminently  judicious, 
from  the  standpoint  of  practical  utility. — Journal  oj 
Cutaneous  and  Venereal  Diseases,  Jan.  1884. 


CORHTIL,  V., 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lour  cine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  William  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  of  Pennsylvania.  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.    Cloth,  $3.75. 

perusal  without  the  feeling  that  his  grasp  of  the 


The  anatomy,  the  histology,  the  pathology  and 
the  clinical  features  of  syphilis  are  represented  in 
this  work  in  their  best,  most  practical  and  most 
instructive  form,  and  no  one  will  rise  from  its 


wide  and  important  subject  on  which  it  treats  is 
a  stronger  and  surer  one. — The  London  Practi- 
tioner, Jan.  1882. 


HUTCHijrsoir,  Jonathan,  f.  r.  s.,  f.  r.  c.  s., 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.    In  one  12mo.  volume  of  542  pages,  with  8  chromo-lithographs.    Cloth , 
$2.25.    Just  ready.    See  Series  of  Clinical  Manuals,  page  4. 

FROM  THE  PREFACE. 
In  the  following  pages  I  have  aimed  less  at  systematic  completeness  than  at  clinical 
exposition.    To  the  latter  subject  I  have  devoted  my  best  efforts,  and  my  hope  is  that 
those  who  may  honor  this  work  by  their  attentive  perusal  will  obtain  from  its  pages  clear 
impressions  on  the  state  of  our  knowledge  on  the  topics  which  it  concerns. 

GROSS,  S.  JO.,  3f.~L>.,  LL.  JO.,  JO.  C.  L„  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thoroughly  revised  by  Samuel  W.  Gross,  M.  D.  In  one  octavo  volume  of  574 
pages,  with  170  illustrations.    Cloth,  $4.50. 

CULLFRIFR,  A.~&  BUMSTFAI),  F.  J.,  M.JO.,  LL.JO., 

Surgeon  to  the  Hdpital  du  Midi.        Late  Professor  of  Venereal  Diseases  in  the  College  of  Physician* 

and  Surgeons,  New  York. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Freeman  J.  Bum- 
stead,  M.  D.  In  one  imperial  4to.  volume  of  328  pages,  double-columns,  with  26  plates, 
containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of  life,  Strongly 
bound  in  cloth,  $17.00.  A  specimen  of  the  plates  and  text  sent  by  mail,  on  rec  eipt  of  'J">  cte. 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  I  FORMS   OF    LOCAL    DISEA8E  AFFECTINo 
DISORDERS.  In  one  8vo  vol.  of 479  p.  Cloth,  $3.25.  !  PRINCIPALLY  THE  ORGANS  OF  GENERA^ 
LEE'S  LECTURES  ON  SYPHILIS  AND  SOME  |  TION.    In  one  8vo.  vol.  of  246  pages.   Cloth.  *2  U,.' 


2fi 


Lea  Brothers  &  Co.'s  Publications— Diseases  of  Skin* 


KAPOSI,  MOBIZ, 

Of  Vienna. 

The  Pathology  and  Treatment  of  Diseases  of  the  Skin.  For  the  use 

of  Practitioners  and  Students.  Translated,  with  the  author's  permission,  by  W  Xavieb 
Sudduth,  M.  D.,  F.  R.  M.  S.  In  one  octavo  volume  of  about  600  pages,  with  74  engrav- 
ings and  8  colored  plates.  Preparing. 

HYDE,  J.  NFVINS,  A.  M.,  M.  !>., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Rush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  and 
Practitioners.  In  one  handsome  octavo  volume  of  570  pages,  with  66  beautiful  and  elab- 
orate illustrations.    Cloth,  $4.25  ;  leather,  $5.25. 


The  author  has  given  the  student  and  practi- 
tioner a  work  admirably  adapted  to  the  wants  of 
each.  We  can  heartily  commend  the  book  as  a 
valuable  addition  to  our  literature  and  a  reliable 
guide  to  students  and  practitioners  in  their  studies 
and  practice. — Am.  Journ.  of  Med.  Sri.,  July,  1883. 

The  aim  of  the  author  has  been  to  present  to  his 
readers  a  work  not  only  expounding  the  most 
modern  conceptions  of  his  subject,  but  presenting 
what  is  of  standard  value.  He  has  more  especially 
devoted  its  pages  to  the  treatment  of  disease,  and 
by  his  detailed  descriptions  of  therapeutic  meas- 
ures has  adapted  them  to  the  needs  of  the  physi- 
cian in  active  practice.  In  dealing  with  the^e 
questions  the  author  leaves  nothing  to  the  pre- 
sumed knowledge  of  the  reader,  but  enters  thor- 
oughly into  the  most  minute  description,  so  that 
one  is  not  only  told  what  should  be  done  under 
given  conditions  but  how  to  do  it  as  well.  It  is 
therefore  in  the  best  sense  "  a  practical  treatise." 
That  it  is  comprehensive,  a  glance  at  the  index 
will  show.— Maryland  Medical  Journal,  July  7,  1883. 


Professor  Hyde  has  long  been  known  as  one  of 
the  most  intelligent  and  enthusiastic  representa- 
tives of  dermatology  in  the  west.  His  numerous 
contributions  to  the  literature  of  this  specialty 
have  gained  for  him  a  favorable  recognition  as  a 
careful,  conscientious  and  original  observer.  He 
has  attempted,  as  he  informs  us,  the  task  of  pre- 
senting in  a  condensed  form  the  results  of  the 
latest  observation  and  experience.  A  careful  ex- 
amination of  the  work  convinces  us  that  he  has 
accomplished  his  task  with  painstaking  fidelity 
and  with  a  creditable  result. — Journal  of  Cutaneous 
and  Venereal  Diseases,  June,  1883. 

The  several  diseases  are  described  very  con- 
cisely, but  at  the  same  time  with  unusual  clear- 
ness. The  treatment  is  given  in  the  simplest  man- 
ner and  apparently  with  great  honesty.  It  is  a 
good  book,  remarkably  adapted  to  the  needs  of 
those  for  whom  it  was  written.  It  should  be  at 
once  placed  in  the  library  of  every  general  practi- 
tioner.— Detroit  Lancet,  April,  1883. 


FOX,  T.,  M.D.,  F.Il.  C.  F.,  and  FOX,  T.  C,  B.A.,  M.R.  C.S., 

Physician  to  the  Department  for  Skin  Diseases,  Physician  for  Diseases  of  the  Skin  to  the 

University  College  Hospital,  London.  Westminster  Hospital,  London. 

An  Epitome  of  Skin  Diseases.  With  Formulae.  For  Students  and  Prac- 
titioners.   Third  edition,  revised  and  enlarged.    In  one  very  handsome  12mo.  volume 

of  238  pages.    Cloth,  $1 .25. 


The  third  edition  of  this  convenient  handbook 
calls  for  notice  owing  to  the  revision  and  expansion 
which  it  has  undergone.  The  arrangement  of  skin 
diseases  in  alphabetical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 
to  students  but  also  to  practitioners  who  require  a 
compendious  summary  of  the  present  state  of 
dermatology. — British  Medical  Journal,  July  2, 1883. 

We  cordially  recommend  Fox's  Epitome  to  those 
whose  time  is  limited  and  who  wish  a  handy 


manual  to  lie  upon  the  table  for  instant  reference. 
Its  alphabetical  arrangement  is  suited  to  this  use, 
for  all  one  has  to  know  is  the  name  of  the  disease, 
and  here  are  its  description  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  has  been  very  carefully 
revised  and  a  number  of  new  diseases  are  de- 
scribed, while  most  of  the  recent  additions  to 
dermal  therapeutics  find  mention,  and  the  formu- 
lary at  the  end  of  the  book  has  been  considerably 
augmented. —  The  Medical  News,  December,  1883. 


MORRIS,  MALCOLM,  F.  R.  C.  $., 

Joint  Lecturer  on  Dermatology  at  St.  Ma  ry's  Hospital  Medical  School,  London. 
Skin  Diseases ;  Including  their  Definitions,  Symptoms,  Diagnosis,  Prognosis,  Mor- 
bid Anatomy  and  Treatment.    A  Manual  for  Students  and  Practitioners.    In  one  12mo. 
volume  of  316  pages,  with  illustrations.    Cloth,  $1.75. 

for  clearness  of  expression  and  methodical  ar- 
rangement is  better  adapted  to  promote  a  rational 
conception  of  dermatology — a  branch  confessedly 
difficult  and  perplexing  to  the  beginner.— Louis 
Courier  of  Medicine,  April,  1880. 

The  writer  has  certainly  given  in  a  small  compass 
a  large  amount  of  well-compiled  information,  and 
his  little  book  compares  favorably  with  any  other 
which  has  emanated  from  England,  while  in  many 
points  he  has  emancipated  himself  from  the  stub- 
bornly adhered  to  errors  of  others  of  his  country- 
men. There  is  certainly  excellent  material  in  the 
book  which  will  well  repay  perusal. — Boston  Med. 
aiu.1  Surg.  Journ.,  March,  1880. 


To  physicians  who  would  like  to  know  something 
about  skin  diseases,  so  that  when  a  patient  pre- 
sents himself  for  relief  they  can  make  a  correct 
diagnosis  and  prescribe  a  rational  treatment  we 
unhesitatingly  recommend  this  little  book  of  Dr. 
Morris.  The  affections  of  the  skin  are  described 
in  a  terse,  lucid  manner,  and  their  several  charac- 
teristics so  plainly  set  forth  that  diagnosis  will  be 
easy.  The  treatment  in  each  case  is  such  as  the 
experience  of  the  most  eminent  dermatologists  ad- 
vises.— Cincinnati  Medical  News,  April,  1880. 

This  is  emphatically  a  learner's  book;  for  we 
«an  safely  say,  that  in  the  whole  range  of  medical 
literature  there  is  no  book  of  a  like  scope  which 


WILSON,  ERASMUS,  F.  R.  S. 

The  Student's  Book  of  Cutaneous  Medicine  and  Diseases  of  the  Skin. 

In  one  handsome  small  octavo  volume  of  585  pages. .  Cloth,  $3.50. 

HILLIER,  THOMAS,  M.  I}., 

Physician  to  the  Skin  Department  of  University  College,  London. 
Handbook  of  Skin  Diseases;  for  Students  and  Practitioners.    Second  Ameri- 
can edition.    In  one  12mo.  volume  of  353  pages,  with  plates.    Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women. 


27 


The  American  Systems  of  Gynecology  and  Obstetrics. 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors.  Gynecology  edited  by  Matthew  J).  Mann,  A.  M.,  M.  D.,  Professor  of  Obstetrics 
and  Gynecology  in  the  Medical  Department  of  the  University  of  Buffalo;  and  Obstet- 
rics edited  by  Barton  Cooke  Hirst,  M.  D.,  Obstetrician  to  the  Philadelphia  and  to  the 
Maternity  Hospitals,  Philadelphia.  In  four  very  handsome  octavo  volumes  of  about  800 
pages  each,  fully  illustrated  by  wood  engravings  and  colored  plates.  Prices  per  volume: 
Cloth,  $6.00;  leather,  $7.00;  half  Kussia,  $8.00.  Volume  I.  of  the  Gynecology,  con- 
taining 784  pages,  with  201  engravings  on  wood  and  3  colored  plates,  is  just  ready.  The 
subsequent  volumes  are  to  follow  at  regular  intervals.  For  sale  by  subscription  only. 
Address  the  Publishers.    Full  descriptive  circular  free  on  application. 

LIST  OF  CONTRIBUTORS, 


WILLIAM  H.  BAKER,  M.  D., 
FORDYCE  BARKER,  M.  D.,  LL.  D.,  Edin., 
ROBERT  BATTEY,  M.  D., 
SAMUEL  C.  BU8EY,  M.  D.. 
JAMES  C.  CAMERON,  M.  D., 
HENRY  C  COE,  A.  M.,  M.  D., 
E.  C  DUDLEY,  A.  B.,  M.  D  , 
EDWARD  S.  DUNSTER,  M.  D., 
B.  McE.  EMMET,  M.  D., 
GEORGE  J.  ENGELMANN,  M.  D., 
HAROLD  C.  ERNST,  M.  D., 
HENRY  J.  GARR1GUES,  A.  M.,  M.  D., 
WILLIAM  GOODELL,  A.  M.,  M.  D., 
EGBERT  H.  GRANDIN,  A.  M.,  M.  D., 
CHARLES  M.  GREEN,  M.  D., 
SAMUEL  W.  GROSS,  M.  D., 
ROBERT  P.  HARRIS,  M.  D., 
STEPHEN  Y.  HOWELL,  M.  D., 
JAMES  B.  HUNTER,  M.  D., 
A.  REEVES  JACKSON,  A.  M.,  M.  D., 
EDWARD  W.  JENKS,  M.  D.,  LL.  D.,' 
JOSEPH  TABER  JOHNSON,  M.  D., 
It  is  exceedingly  fitting  that  a  System  of  Gyne- 
cology should  be  given  forth  as  the  product  of 
American  pens.   America  is  the  fountain  of  mod- 
ern gynecology,  and  has  contributed  more  than 
any  other  country  to  its  development.   All  things 
considered,  the  best  treatise  on  gynecology  must 
be  expeded  from  this  country,  and  when  the 
gynecologists  of  this  country  unite  their  efforts  in 


CHARLES  CARROLL  LEE,  M.  D., 
WILLIAM  T.  LUSK,  M.  D.,  LL.  D., 
MATTHEW  D.  MANN,  A.  M.,  M.  D., 
H.  NEWELL  MARTIN,  F.  R.  S.,  M.  D., 

D.Sc  ,  M.A., 
RICHARD  B.  MAURY,  M.  D., 
PAUL  F.  MUNDE,  M.  D., 
C.  D.  PALMER,  M.  D., 
ROSWELL  PARK,  M.  D., 
THEOPHILUS  PARVIN,  M.  D.,  LL.  D., 
R.  A.  F.  PENROSE,  M.  D.,  LL  D., 
THADDEUS  A.  REAMY,  A.  M.,  M.  D., 
J.  C.  REEVE,  M.  D., 
WILLIAM  L.  RICHARDSON,  M.  D., 
A.  D.  ROCKWELL,  A.  M.,  M.  D., 
ALEXANDER  J.  C.  SKENE,  M.  D., 
J.  LEWIS  SMITH,  M.  D., 
R.  STANSBURY  SUTTON,  A.  M.,  M.  D., 
LL.  D., 

T.  GAILLARD  THOMAS,  M.  D.,  LL.  D., 
ELY  VAN  DE  WARKER,  M.  D., 
W.  GILL  WYLIE,  M.  D. 
a  "system,"  the  result  would  be  disappointing 
were  it  not  to  excel  anything  of  the  kind  hereto- 
fore attempted.     An  examination  of   the  first 
volume  of  the  work  before  us  justifies  every 
expectation  formed  of  it.    We  must  commend  it  to 
every  reader  interested  in  the  division  of  medicine 
of  which  it  treats.—  The  Medical  Age,  July  25, 1887. 


THOMAS,  T.  GAILLARD,  M. 

Professor  of  Diseases  of  Women  in  the  College  of  Physicians  and  Surgeons,  N.  T. 

A  Practical  Treatise  on  the  Diseases  of  Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  handsome  octavo  volume  of  810  pages,  with  266 
illustrations.    Cloth,  $5.00 ;  leather,  $6.00 ;  very  handsome  half  Russia,  raised  bands,  $6.50. 

The  words  which  follow  "fifth  edition"  are  in 
this  case  no  mere  formal  announcement.  The 


alterations  and  additions  which  have  been  made  are 
both  numerous  and  important.  The  attraction 
and  the  permanent  character  of  this  book  lie  in 
the  clearness  and  truth  of  the  clinical  descriptions 
of  diseases;  the  fertility  of  the  author  in  thera- 

Seutic  resources  and  the  fulness  with  which  the 
etails  of  treatment  are  described;  the  definite 
character  of  the  teaching;  and  last,  but  not  least, 
the  evident  candor  which  pervades  it.  We  would 
also  particularize  the  fulness  with  which  the  his- 
tory of  the  subject  is  gone  into,  which  makes  the 


book  additionally  interesting  and  gives  it  value  as 
a  work  of  reference. — London  Medical  Times  and 


Gazette,  July  30, 1881. 

That  the  previous  editions  of  the  treatise  of  Dr. 
Thomas  were  thought  worthy  of  translation  into 
German,  French,  Italian  and  Spanish,  is  enough 
to  give  it  the  stamp  of  genuine  merit.  At  home  it 
has  made  its  way  into  the  library  of  every  obstet- 
rician and  gynaecologist  as  a  safe  guide  to  practice. 
No  small  number  of  additions  have  been  made  to 
the  present  edition  to  make  it  correspond  to  re- 
cent improvements  in  treatment.— Pacific  Medical 
and  Surgical  Journal,  Jan.  1881. 


EDIS,  ARTHUR  W.,  M.  !>.,  Lond.,  F.R.  C.F.,  M.R.  C.S.9 

Assist.  Obstetric  Ph'jsician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 
The  Diseases  Of  Women.    Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.    A  Manual  for  Students  and  Practitioners.    In  one  handsome 
octavo  volume  of  576  pages,  with  148  illustrations.    Cloth,  $3.00 ;  leather,  $4.00. 


It  is  a  pleasure  to  read  a  book  so  thoroughly 
good  as  this  one.  The  special  qualities  which  are 
conspicuous  are  thoroughness  in  covering  the 
whole  ground,  clearness  of  description  and  con- 
ciseness of  statement.  Another  marked  feature  of 
the  book  is  the  attention  paid  to  the  details  of 
many  minor  surgical  operations  and  procedures, 
as,  for  instance,  the  use  of  tents,  application  of 
leeches,  and  use  of  hot  water  injections.  These 


are  among  the  more  common  methods  of  treat- 
ment, and  yet  very  little  is  said  about  them  in 
many  of  the  text-books.  The  book  is  one  to  be 
warmly  recommended  especially  to  students  and 
general  practitioners,  who  need  a  concise  but  com- 
plete rteumt  of  the  whole  subject.  Specialists,  too,, 
will  find  many  useful  hints  in  its  pages. — Boston 
Med.  and  Surg.  Journ.,  March- 2,  1882. 


BARNES,  ROBERT,  M.  L>.,  F.  R.  C.  P., 

Obstetric  Physician  to  St.  Thomas'1  Hospital,  London,  etc. 

A  Clinical  Exposition  of  the  Medical  and  Surgical  Diseases  of  Women. 
In  one  handsome  octavo  volume,  with  numerous  illustrations.    New  edition.  Preparing. 

WEST,  CHARLES,  M.  1). 

Lectures  on  the  Diseases  of  Women.  Third  American  from  the  third  Lon- 
don edition.    In  one  octavo  volume  of  543  pages.    Cloth,  $3.75 ;  leather,  $4.75. 


28 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women,  Midwfy . 


EMMET,  THOMAS  ADDIS,  M.  D.,  LL.  D.,  ^ 

Surgeon  to  the  Woman's  Hospital,  New  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  New  (third)  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  $5 ;  leather,  $6 ; 
very  handsome  half  Russia,  raised  bands,  $6.50. 


We  are  in  doubt  whether  to  congratulate  the 
author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  work. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  himself 
as  a  bold  and  successful  operator,  and  who  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 
the  privilege  thus  offered  them  of  perusing  the 
views  and  practice  of  the  author.  His  earnestness 
of  purpose  and  conscientiousness  are  manifest. 
He  gives  not  only  his  individual  experience  but 
endeavors  to  represent  the  actual  state  of  gynae- 
cological science  and  art. — British  Medical  Jour- 
nal, May  16, 1885. 

No  jot  or  tittle  of  the  high  praise  bestowed  upon 
the  first  edition  is  abated.  It  is  still  a  book  of 
marked  personality,  one  based  upon  large  clinical 
experience,  containing  large  and  valuable  ad- 
ditions to  our  knowledge,  evidently  written  not 
only  with  honesty  of  purpose,  but  with  a  conscien- 
tious sense  of  responsibility,  and  a  book  that  is  at 


once  a  credit  to  its  author  and  to  American  med- 
ical literature.  We  repeat  that  it  is  a  book  to  be 
studied,  and  one  that  is  indispensable  to  every 
practitioner  giving  any  attention  to  gynaecology.— 
American  Journal  of  the  Medical  Sciences,  April,  1885. 

The  time  has  passed  when  Emmet's  Gynaecology 
was  to  be  regarded  as  a  book  for  a  single  country 
or  for  a  single  generation.  It  has  always  been  his 
aim  to  popularize  gynaecology,  to  bring  it  within 
easy  reach  of  the  general  practitioner.  The  orig- 
inality of  the  ideas,  aside  from  the  perfect  con- 
fidence which  we  feel  in  the  author's  statements, 
compels  our  admiration  and  respect.  We  may 
well  take  an  honest  pride  in  Dr.  Emmet's  work 
and  feel  that  his  book  can  hold  its  own  against  the 
criticism  of  two  continents.  It  represents  all  that 
is  most  earnest  and  most  thoughtful  in  American 
gynaecology.  Emmet's  work  will  continue  to 
reflect  the  individuality,  the  sterling  integrity  and 
the  kindly  heart  of  its  honored  author  long  after 
smaller  books  have  been  forgotten. — American 
Journal  of  Obstetrics,  May,  1885. 


Z>  U JVC  AW,  J.  MATTHEWS,  M.D.,  LL.  D.,  I.  JR.     E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women;  Delivered  in  Saint  Bar- 
tholomew's Hospital.    In  one  handsome  octavo  volume  of  175  pages.    Cloth,  $1.50. 
They  are  in  every  way  worthy  ol  their  author  ;   rule,  adequately  handled  in  the  text-books ;  others 

of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 
stamp  of  individuality  that  they  deserve  to  be 
widely  read. — N.  Y.  Medical  Journal,  March,  1880. 


ey 

indeed,  we  look  upon  them  as  among  the  most 
valuable  of  his  contributions.  They  are  all  upon 
matters  of  great  interest  to  the  general  practitioner. 
Some  of  them  deal  with  subjects  that  are  not,  as  a 


MAT,  C II Alt  LBS  JET.,  M.  D. 

Late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York. 
A  Manual  of  the  Diseases  of  Women.  Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynaecology.     In  one  12mo.  volume  of  342  pages. 
Cloth,  $1.75. 


Medical  students  will  find  this  work  adapted  to 
their  wants.  Also  practitioners  of  medicine  will 
find  it  exceedingly  convenient  to  consult  for  the 
purpose  of  refreshing  their  minds  upon  the  lead- 
ing points  of  a  gynaecological  subject.  By  syste- 
matic condensation,  the  omission  of  disputed  ques- 


tions, and  the  presentation  only  of  accepted  views, 
it  constitutes  a  very  satisfactory  exposition  of  the 
leading  principles  of  gynaecology  as  they  are  un- 
derstood at  the  present  time. — Cincinnati  Medical 
News,  Nov.  1885. 


HODGE,  HVGH  L.,  M.  D., 

Emeritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 
On  Diseases  Peculiar  to  Women;  Including  Displacements  of  the  Uterus. 
Second  edition,  revised  and  enlarged.    In  one  beautifully  printed  octavo  volume  of  519 
pages,  with  original  illustrations.    Cloth,  $54.50. 

By  the  Same  Author. 
The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  numerous  wood- 
cuts. In  one  large  quarto  volume  of  542  double-columned  pages.  Strongly  bound  in 
cloth,  $14.00.  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address, 
free  by  mail,  on  receipt  of  six  cents  in  postage  stamps. 

BAMSBOTHAM,  EttAJTCIS  H.,  M.  D. 

The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery; 

In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly  revised 
by  the  Author.  With  additions  by  W.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.    Strongly  bound  in  leather,  with  raised  bands,  $7. 

WIWC  KEL  ,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.  Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  by  J.  E.  Chadwick,  M.  D.    Octavo  484  pages.    Cloth,  $4.00. 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE 
DISEASES  PECULIAR  TO  WOMEN.  Third 
American  from  the  third  and  revised  London 
edition.    In  one  8vo.  vol.,  pp.  520.   Cloth.  $3.50. 

CHURCHILL  ON  THE  PUERPERAL  FEVER 


AND  OTHER  DISEASES  PECULIAR  TO  WO- 
MEN. In  one  8vo.  vol.  of  464  pages.  Cloth,  $2.50. 
MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  In  one  8vo. 
volume  of  346  pages.   Cloth,  $2.00. 


iwbi    I«ea  Brothers  &  Co.'s  Publications — Midwifery. 


29 


PARVIN,  THEOPSILVS,  M.  JD.,  LL.  D., 

Prof,  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jefferson  Med.  Coll. ,  Phila. 

The  Science  and  Art  of  Obstetrics.  In  one  handsome  8vo.  volume  of  697 
pages,  with  214  engravings  and  a  colored  plate.    Cloth,  $4.25  ;  leather,  $5.25. 


It  is  a  ripe  harvest  that  Dr.  Parvin  offers  to  his 
readers.  There  is  no  book  that  can  be  more  safely 
recommended  to  the  student  or  that  can  be  turned 
to  in  moments  of  doubt  with  greater  assurance  of 
aid,  as  it  is  a  liberal  digest  of  safe  counsel  that  has 
been  patiently  gathered.—  The  American  Journal 
of  the  Medical  Sciences,  July,  1887. 

There  is  not  in  the  language  a  treatise  on  the 
subject  which  so  completely  and  intelligently 
gleans  the  whole  field  of  obstetric  literature,  giv- 
ing the  reader  the  winnowed  wheat  in  concise  and 
well-jointed  phrase,  in  language  of  exceptional 
purity  and  strength.  The  arrangement  of  the 
matter  of  this  work  is  unique  and  exceedingly 


favorable  for  an  agreeable  unfolding  of  the  science 
and  art  of  obstetrics.  This  new  book  is  the  easy 
superior  of  any  single  work  among  its  predeces- 
sors for  the  student  or  practitioner  seeking  the 
best  thought  of  the  day  in  this  department  of 
medicine. —  The  American  Practitioner  and  News, 
April  2,  1887. 

This  treatise  may  be  defined  as  exact,  concise 
and  scholarly.  Parvin's  distinguished  position  as 
a  teacher,  his  scholarly  attainments,  and  his 
honest  endeavor  to  do  his  best  by  both  the  student 
and  the  physician,  will  secure  for  his  treatise 
favorable  recognition. — American  Journal  of  Obstet- 
rics, May,  1887. 


BARNES,  ROBERT,  M.I).,  and  FANCOURT,  M.  !>., 

Phys.  to  the  General  Lying-in  Hosp.,  Lond.  Obstetric  Phys.  to  St.  Thomas1  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.  In  one  handsome  octavo  volume  of  872  pages,  with  231  illus- 
trations. Cloth,  $5  ;  leather,  $6. 


This  system  will  be  eagerly  sought  for,  not  only 
on  account  of  its  intrinsic  merit,  but  also  because 
the  reputation  which  the  elder  Barnes,  in  particu- 
lar, has  secured,  carries  with  it  the  conviction  that 
any  book  emanating  from  him  is  necessarily  sound 
in  teaching  and  conservative  in  practice.  It  is  in- 
deed eminently  fitting  that  a  man  who  has  done  so 
much  towards  systematizing  the  obstetric  art,  who 
for  so  many  years  has  been  widely  known  as  a  capa- 


ble teacher  and  trusted  accoucheur,  should  embody 
within  a  single  treatise  the  system  which  he  has 
taught  and  in  practice  tested,  and  which  is  the  out- 
come of  a  lifetime  of  earnest  labor,  careful  obser- 
vation and  deep  study.  The  result  of  thi9  arrange- 
ment is  the  production  ol  a  work  which  rises  above 
criticism  and  which  in  no  respect  need  yield  the 
palm  to  any  obstetrical  treatise  hitherto  published. 
— American  Journal  of  Obstetrics,  Feb.  1886. 


PLATE  AIR,  W.  S.,  M.  D.,  F.  R.  C.  P., 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  New  (fourth) 
American,  from  the  fifth  English  edition.  Edited,  with  additions,  by  Robert  P.  Har- 
ris, M.  D.  In  one  handsome  octavo  volume  of  654  pages,  with  3  plates  and  201  engrav- 
ings.   Cloth,  $4 ;  leather,  $5 ;  half  Russia,  $5.50. 


This  still  remains  a  favorite  in  America,  not 
only  because  the  author  is  recognized  as  a  safe 
guide  and  eminently  progressive  man,  but  also  as 
sparing  no  effort  to  make  each  successive  edition 
a  faithful  mirror  of  the  latest  and  best  practice. 
A  work  so  frequently  noticed  as  the  present 
requires  no  further  review.  We  believe  that  this 
edition  is  simply  the  forerunner  of  many  others, 
and  that  the  demand  will  keep  pace  with  the 


supply. — American  Journal  of  Obstetrics,  Nov.  1885. 

Since  its  first  publication,  only  eight  years  ago, 
it  has  rapidly  become  the  favorite  text-book,  to 
the  practical  exclusion  of  all  others.  A  large 
measure  of  its  popularity  is  due  to  the  clear  and 
easy  style  in  which  it  is  written.  Few  text-books 
for  students  have  very  much  to  boast  of  in  this 
respect. — Medical  Record. 


KING,  A.  F.  A.,  M.  I)., 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 
A  Manual  of  Obstetrics.    New  (third)  edition.    In  one  very  handsome  12mo. 
volume  of  376  pages,  with  102  illustrations.    Cloth,  $2.25. 

bul  ky— it  is  concise.  The  chap  t ers  are  divided  with 
sub- headings,  which  aid  materially  in  the  finding 
of  any  particular  subject,  and  the  definitions  are 
clear  and  explicit.  It  fulfils  its  purpose  admirably, 
and  we  know  of  no  better  work  to  place  in  the  stu- 
dent's hands.  The  illustrations  are  good.— Arch- 
ives of  Gynecology,  January,  1887. 


This  little  manual,  certainly  the  best  of  its  kind, 
fully  deserves  the  popularity  which  has  made  a 
third  edition  necessary.  Clear,  practical,  concise, 
its  teachings  are  so  fully  abreast  with  recent  ad- 
vances in  obstetric  science  that  but  few  points 
can  be  criticised. — American  Journal  of  Obstetrics, 
March,  1887. 

This  volume  deserves  commendation.   It  is  not 


BARKER,  FORDYCE,  A.  M.,  M.  2>.,  LL.  I).  Edin., 

Clinical  Professor  of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical  College, 
New  York,  Honorary  Fellow  of  the  Obstetrical  Societies  of  London  and  Edinburgh,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.  In  one  handsome  12mo.  volume  of  about 
300  pages.  Preparing. 

BARNES,  FAN  CO  URT,  M~JLX, 

Obstetric  Physician  to  St.  Thomas'  Hospital,  London. 

A  Manual  of  Midwifery  for  Midwives  and  Medical  Students,  [n  one 
royal  12mo.  volume  of  197  pages,  with  50  illustrations.    Cloth,  $1.25. 


PARRY,  JOHN  $.,  M.  D., 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-President  of  the  Obstet.  Society  of  Philadelphia. 

Extra  -  Uterine  Pregnancy:  Its  Clinical  History,  Diagnosis,  Prognosis  sad 
Treatment.    In  one  handsome  octavo  volume  of  272  pages.    Cloth,  $2.50, 


TANNER  ON  PREGNANCY.   Octavo,  490  pages,  4  colored  plates,  16  cuts.   Cloth,  S4.Jf.. 


30 


Lea  Brothers  &  Co.'s  Publications — Midwfy.,  Dis.  Childn. 


LEISIIMAN,  WILLIAM,  M.  I)., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  etc. 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50 ;  very  handsome  half  Russia,  raised  bands,  $6.00. 

must  prove  admirably  adapted.  Complete  in  all  its 

Sarts,  essentially  modern  in  its  teachings,  and  with 
emonstrations  noted  for  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  as  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended. — N.  O. 
Med.  and  Surg.  Journ.,  March.  1880. 

It  has  been  well  and  carefully  written.  The 
views  of  the  author  are  broad  and  liberal,  and  in- 
dicate a  well-balanced  judgment  and  matured 
mind.  We  observe  no  spirit  of  dogmatism,  but 
the  earnest  teaching  of  the  thoughtful  observer 
and  lover  of  true  science.  Take  the  volume  as  a 
whole,  and  it  has  few  equals. — Maryland  Medical 
Journal,  Feb.  1880. 


The  author  is  broad  in  his  teachings,  and  dis- 
cusses briefly  the  comparative  anatomy  of  the  pel- 
vis and  the  mobility  of  the  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  study  of  the  pelvis,  while  in  the  third  the 
female  organs  of  generation  are  introduced. 
The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plain  and  pleasing.  It  is  sufficient  to  state  that  in 
this,  the  last  edition  of  this  well-known  work,  every 
recent  advancement  in  this  field  has  been  brought 
forward. — Physician  and  Surgeon,  Jan.  1880. 

To  the  American  student  the  work  before  us 


LAWDIS,  HENRY  G.,  A.  M.,  M.  !>., 

Professor  of  Obstetrics  and  the  Diseases  of  Women  in  Starling  Medical  College,  Columbus,  O. 

The  Management  of  Labor,  and  of  the  Lying-in  Period.    In  one 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.    Cloth,  $1.75. 

The  author  has  designed  to  place  in  the  hands 
of  the  young  practitioner  a  book  in  which  he  can 
find  necessary  information  in  an  instant/  As  far 
as  we  can  see,  nothing  is  omitted.  The  advice  is 
sound,  and  the  proceedures  are  safe  and  practical. 


Centralb/att  fur  Gynakvlogie,  December  4,  1886. 

This  is  a  book  we  can  heartily  recommend. 
The  author  goes  much  more  practically  into  the 
details  of  the  management  of  labor  than  most 
text-books,  and  is  so  readable  throughout  as  to 


tempt  any  one  who  should  happen  to  commence 
the  book  to  read  it  through.  The  author  pre- 
supposes a  theoretical  knowledge  of  obstetrics, 
and  has  consistently  excluded  from  this  little 
work  everything  that  is  not  of  practical  use  in  the 
lying-in  room.  We  think  that  if  it  is  as  widely 
read  as  it  deserves,  it  will  do  much  to  improve 
obstetric  practice  in  general. — New  Orleans  Medi- 
cal and  Surgical  Journal,  Mar.  1886. 


SMITH,  J.  LEWIS,  M.  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  T. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.   New  (sixth) 

edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  867 
pages,  with  40  illustrations.    Cloth,  $4.50 ;  leather,  $5.50  ;  half  Kussia,  $6.00. 


Rarely  does  a  pleasanter  task  fall  to  the  lot  of 
the  bibliographer  than  to  announce  the  appearance 
of  a  new  edition  of  a  medical  classic  like  Prof.  J. 
Lewis  Smith's  Treatise  on  the  Diseases  of  Infancy 
and  Childhood.  For  years  it  has  stood  high  in  the 
confidence  of  the  profession,  and  with  the  addi- 
tions and  alterations  now  made  it  may  be  said  to 
be  the  best  book  in  the  language  on  the  subject  of 
which  it  treats.  An  examination  of  the  text  fully 
sustains  the  claims  made  in  the  preface,  that  "in 
preparing  the  sixth  edition  the  author  has  revised 
the  text  to  such  an  extent  that  a  considerable 
part  of  the  book  may  be  considered  new."  If  the 
young  practitioner  proposes  to  place  in  his  library 
but  one  book  on  the  diseases  of  children,  we 
would  unhesitatingly  say,  let  that  book  be  the  one 
which  is  the  subject  of  this  notice. —  The  American 
Journal  of  the  Medical  Sciences,  April,  1886. 

No  better  work  on  children's  diseases  could  be 
placed  in  the  hands  of  the  student,  containing,  as 
it  does,  a  very  complete  account  of  the  symptoms 
and  pathology  of  the  diseases  of  early  life,  and 
possessing  the  further  advantage,  in  which  it 


stands  alone  amongst  other  works  on  its  subject, 
of  recommending  treatment  in  accordance  with 
the  most  recent  therapeutical  views.— British  and 
Foreign  Medico-Chirurgical  Review. 

It  is  a  pleasure  to  the  busy  practitioner — inter- 
ested in  the  advancement  of  his  profession— to 
meet,  fresh  from  the  hands  of  its  author,  a  medi- 
cal classic  such  as  Smith  on  Diseases  of  Children. 
Those  familiar  with  former  editions  of  the  work 
will  readily  recognize  the  painstaking  with  which 
this  revision  has  been  made.  Many  of  the  articles 
have  been  entirely  rewritten.  The  whole  work  is 
enriched  with  a  research  and  reasoning  which 
plainly  show  that  the  author  has  spared  neither 
time  nor  labor  in  bringing  it  to  its  present  ap- 
proach towards  perfection.  The  extended  table  of 
contents  and  the  well-prepared  index  will  enable 
the  busy  practitioner  to  reach  readily  and  quickly 
for  reference  the  various  subjects  treated  of  in  the 
body  of  the  work,  and  even  those  who  are  familiar 
with  former  editions  will  find  the  improvements 
in  the  present  richly  worth  the  cost  of  the  work. — 
Atlanta  Medical  and  Surgical  Journal,  Dec.  1886. 


OWEN,  EDMUND,  M.  B.,  F.  M.  C.  S., 

Surgeon  to  the  Children's  Hospital,  Great  Ormond  St.,  London. 

Surgical  Diseases  of  Children.  In  one  12mo.  volume  of  525  pages,  with  4 
chromo-lithographic  plates  and  85  woodcuts.  Cloth,  $2.  See  Series  of  Clinical  Manuals, 
page  4. 


One  is  immediately  struck  or  reading  this  book 
with  its  agreeable  style  and  the  evidence  it  every- 
where presents  of  the  practical  familiarity  of  its 
author  with  his  subject.     The  book  may  be 


honestly  recommended  to  both  students  and 
practitioners.  It  is  full  of  sound  information, 
pleasantly  given.— A nnals  of  Surgery,  May,  1886. 


WEST,  CHAMLES,  M.  D., 

Physician  to  the  Hospital  for  Sick  Children,  London,  etc. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood. 

12mo.  volume  of  127  pages.    Cloth,  $1.00. 


In  one  small 


WEST'S  LECTURES  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.   In  one  octavo  vol. 
CONDIE'S   PRACTICAL  TREATISE  ON  THE 


DISEASES  OF  CHILDREN.  Sixth  edition,  re- 
vised and  augmented.  In  one  octavo  volume  of 
779  pages.   Cloth,  $5.25;  leather,  $6.26. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  Miscel.  31 


TIDY,  CHARLES  MEYMOTT,  M.  B.,  F.  C.  S., 

Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  etc. 

Legal  Medicine.  Volume  IL  Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Rape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.  Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.    Cloth,  $6.00 ;  leather,  $7.00. 

Volume  I.  Containing  664  imperial  octavo  pages,  with  two  beautiful  colored 
plates.    Cloth,  $6.00 ;  leather,  $7.00. 

The  satisfaction  expressed  with  the  first  portion  tables  of  cases  appended  to  each  division  of  the 
of  this  work  is  in  no  wise  lessened  by  a  perusal  of  subject  must  have  cost  the  author  a  prodigious 
the  second  volume.  We  find  it  characterized  by  amount  of  labor  and  research,  but  they  constitute 
the  same  fulness  of  detail  and  clearness  of  ex-  one  of  the  most  valuable  features  of  the  book, 
pression  which  we  had  occasion  so  highly  to  com-  especially  for  reference  in  medico-legal  trials. — 
mend  in  our  former  notice,  and  which  render  it  so  American  Journal  of  the  Medical  Sciences,  April,  1884. 
valuable  to  the  medical  jurist.     The  copious 


TAYLOR,  ALFRED  &.,  M.  L>., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital,  London. 

A  Manual  of  Medical  Jurisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edited  by  John  J.  Reese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00 ;  leather,  $6.00;  half 
Russia,  raised  bands,  $6.50. 


The  American  editions  of  this  standard  manual 
have  for  a  long  time  laid  claim  to  the  attention  of 
the  profession  in  this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject 
to  which  he  devoted  his  life  with  an  assiduity  and 
success  which  made  him  Jacile  princeps  among 
English  writers  on  medical  jurisprudence.  Both 
the  author  and  the  book  have  made  a  mark  too 
deep  to  be  affected  by  criticism,  whether  it  be 
censure  or  praise.  In  thi3  case,  however,  we  should 


only  have  to  seek  for  laudatory  terms. — American 
Journal  of  the  Medical  Sciences,  Jan.  1881. 

This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  thirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  is 
simply  indispensable  to  every  physician,  and  nearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26,  1881. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Medical  Jurisprudence.  Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations.  Cloth,  $10 ; 
leather,  $12. 


For  years  Dr.  Taylor  was  the  highest  authority 
in  England  upon  the  subject  to  which  he  gave 
especial  attention.  His  experience  was  vast,  his 
.judgment  excellent,  and  his  skill  beyond  cavil.  It 
is  therefore  well  that  the  work  of  one  who,  as  Dr. 
Stevenson  says,  had  an  "enormous  grasp  of  all 


matters  connected  with  the  subject,"  should  be 
brought  up  to  the  present  day  and  continued  in 
its  authoritative  position.  To  accomplish  this  re- 
sult Dr.  Stevenson  has  subjected  it  to  most  careful 
editing,  bringing  it  well  up  to  the  times. — Ameri- 
can Journal  of  the  Medical  Sciences,  Jan.  1884. 


By  the  Same  Author. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.  Third 
American,  from  the  third  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.    Cloth,  $5.50 ;  leather,  $6.50. 

PEPPER,  AUGUSTUS  J.,  M.  S.,  M.  B.,  F.  R.  C.  S., 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 
Forensic  Medicine.   In  one  pocket-size  12mo.  volume.   Preparing.   See  Students' 
Series  of  Manuals,  page  4. 

LEA,  HENRY  C. 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revised  and  enlarged  edition.  In  one 
handsome  royal  12mo.  volume  of  552  pages.    Cloth,  $2.50. 

This  valuable  work  is  in  reality  a  history  of  civ- 
ilization as  interpreted  by  the  progress  of  jurispru- 
dence. .  .  In  "Superstition  and  Force"  we  have  a 
philosophic  survey  of  the  long  period  intervening 
between  primitive  barbarity  and  civilized  enlight- 
enment.  There  is  not  a  chapter  in  the  work  that 


should  not  be  most  carefully  studied ;  and  however 
well  versed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of  so- 
cial science.—  Westminster  Revieic,  Jan.  1880. 


By  the  Same  Author. 
Studies  in  Church  History.   The  Rise  of  the  Temporal  Power— Ben- 


efit of  Clergy— Excommunication. 

octavo  volume  of  605  pages.    Cloth,  $2.50. 

The  author  is  pre-eminently  a  scholar.  He  takes 
up  every  topic  allied  with  the  leading  theme,  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  ol  information 
compressed  into  the  book  is  extraordinary.  In  no 
other  single  volume  is  the  development  of  the 


New  edition.    In  one  very  handsome  royal 

primitive  church  traced  with  so  much  clearness, 
and  with  so  definite  a  perception  of  complex  or 
conflicting  sources.  The  fifty  pages  on  the  growth 
of  the  papacy,  for  instance,  are  admirable  for  con- 
ciseness ana  freedom  from  prejudice. — BoMton 
Traveller,  May  3, 1883. 


Allen's  Anatomy  .... 
American  Journal  of  the  Medical  Sciences 
American  Systems  of  Gynecology  . 
American  System  of  Practical  Medicine . 
An  American  System  of  Dentistry 
♦Ashhurst's  Surgery  .... 
Ashwell  on  Diseases  of  Women 
Attfi  eld's  Chemistry  .... 
Ball  on  the  Rectum  and  Anus 
Barker's  Obstetrical  and  Clinical  Essays, 
Barlow's  Practice  of  Medicine 
Barnes'  Midwifery  .... 
♦Barnes  on  Diseases  of  Women 
Barnes'  System  of  Obstetric  Medicine 
Bartholow  on  Electricity 
Bartholow's  New  Remedies  and  their  Uses 
Basham  on  Renal  Diseases  . 
Bell's  Comparative  Physiology  and  Anatomy 
Bellamy's  Operative  Surgery 
Bellamy's  Surgical  Anatomy 
Blandford  on  Insanity 
Bloxam's  Chemistry 
*Bristowe's  Practice  of  Medicine  . 
Broadbent  on  the  Pulse 
Browne  on  the  Ophthalmoscope 
Browne  on  the  Throat,  Nose  and  Ear 
Bruce's  Materia  Medica  and  Therapeutics 
Brunton's  Materia  Medica  and  Therapeutics 
Bryant  on  the  Breast  .... 
♦Bryant's  Practice  of  Surgery 
*Bumstead  on  Venereal  Diseases  . 
♦Burnett  on  the  Ear  .... 
Butlin  on  the  Tongue  .... 
Carpenter  on  the  use  and  Abuse  of  Alcohol 
♦Carpenter's  Human  Physiology  . 
Carter  &  Frost's  Ophthalmic  Surgery 
Century  of  American  Medicine 
Chambers  on  Diet  and  Regimen 
Chapman's  Human  Physiology 
Charles'  Physiological  and  Pathological  Chem. 
Churchill  on  Puerperal  Fever 
Clarke  and  Lockwood's  Dissectors'  Manual 
Classen's  Quantitative  Analysis 
Cleland's  Dissector  .... 
Clouston  on  Insanity  .... 
Clowes'  Practical  Chemistry 
Coats'  Pathology  .... 
Cohen  on  the  Throat  .... 
Coleman's  Dental  Surgery 
Condie  on  Diseases  of  Children 
Cornil  on  Syphilis  .... 
♦Cornil  and  Ranvier's  Pathological  Histology 
Cullerier's  Atlas  of  Venereal  Diseases 
Curnow's  Medical  Anatomy 
Dalton  on  the  Circulation 
♦Dalton's  HumanPhysiology 
Davis'  Clinical  Lectures 
Draper's  Medical  Physics 
Druitt's  Modern  Surgery    '  . 
Duncan  on  Diseases  of  Women 
♦Dunglison's  Medical  Dictionary  . 
Edes'  Materia  Medica  and  Therapeutics 
Edis  on  Diseases  of  Women  . 
Ellis'  Demonstrations  of  Anatomy 
Emmet's  Gynecology 
♦Erichsen's  System  of  Surgery 
Esmarch's  Early  Aid  in  Injuries  and  Accid'ts 
Farquharson's  Therapeutics  and  Mat.  Med. 
Fenwick's  Medical  Diagnosis 
Finlayson's  Clinical  Diagnosis 
Flint  on  Auscultation  and  Percussion 
Flint  on  Phthisis  .... 
Flint  on  Physical  Exploration  of  the  Lungs 
Flint  on  Respiratory  Organs 
Flint  on  the  Heart  .... 
Flint's  Essays  ... 
♦Flint's  Practice  of  Medicine 
Folsom's  Laws  of  U.  S.  on  Custody  of  Insane 
Foster's  Physiology  .... 
♦Foth  ergil  lvs  Handbook  of  Treatment  . 
Fownes'  Elementary  Chemistry 
Fox  on  Diseases  of  the  Skin  . 
Frankland  and  Japp's  Inorganic  Chemistry 
Fuller  on  the  Lungs  and  Air  Passages  . 
Galloway's  Analysis  . 
Gibney's  Orthopaedic  Surgery 
Gould's  Surgical  Diagnosis  . 
♦Gray's  Anatomy  ..... 
Greene's  Medical  Chemistry  . 
Green's  Pathology  and  Morbid  Anatomy 
Griffith's  Universal  Formulary 
Gross  on  Foreign  Bodies  in  Air-Passages 
Gross  on  Impotence  and  Sterility  . 
Gross  on  Urinary  Organs 
♦Gross'  System  of  Surgery 
Habershon  on  the  Abdomen 
♦Hamilton  on  Fractures  and  Dislocations 
Hamilton  on  Nervous  Diseases 
Hartshorne's  Anatomy  and  Physiology 
Hartshorne's  Conspectus  of  the  Med.  Sci 
Hartshorne's  Essentials  of  Medicine 
Hartshorne's  Household  Medicine 
Hermann's  Experimental  Pharmacology 
Hill  on  Syphilis  ..... 
Hillier's  Handbook  of  Skin  Diseases 
Hoblyn's  Medical  Dictionary 
Hodge  on  Women  .... 
Hodge's  Obstetrics  .... 
Hoffmann  and  Power's  Chemical  Analysis 
Holden's  Landmarks  .... 
Holland's  Medical  Notes  and  Reflections 


Sciences 


4,20 
29 
17 
29 
27 
29 
•17 
11 
24 
4,  7 
4,20 


14 

4, 18 
23 
18 
11 
11 

4,21 
21 
25 
23 

4,21 


14 
17 

8 
10 
28 
4,6 
10 

5 
19 
10 
13 
18 
24 
30 
25 
13 
25 
4,  6 

7 

8 
17 

7 
20 
28 

4 
12 
27 

7 
28 
21 
24 
12 
16 
16 
18 
18 
18 
18 
18 
18 
14 
19 


18 
8 
20 
4,  21 
5 
10 
13 
11 
IS 
25 
25 
20 
16 
22 
19 
6 
3 
14 
17 
11 
25 
26 
4 

28 
28 
10 
5 
17 


♦Holmes'  System  of  Surgery 
Horner's  Anatomy  and  Histology  . 
Hudson  on  Fever 
Hutchinson  on  Syphilis 
Hyde  on  the  Diseases  of  the  Skin  . 
Jones  (C.  Handheld)  on  Nervous  Disorders 
Juler's  Ophthalmic  Science  and  Practice 
Kaposi  on  Skin  Diseases 
King's  Manual  of  Obstetrics  . 
Klein's  Histology  .... 
Landis  on  Labor  .... 
La  Roche  on  Pneumonia,  Malaria,  etc.  . 
La  Roche  on  Yellow  Fever  . 
Laurence  and  Moon's  Ophthalmic  Surgery 
Lawson  on  the  Eye,  Orbit  and  Eyelid 
Lea's  Studies  in  Church  History 
Lea's  Superstition  and  Force 
Lee  on  Syphilis 

Lehmann  s  Chemical  Physiology  . 
♦Leishman's  Midwifery 
Lucas  on  Diseases  of  the  Urethra  . 
Ludlow's  Manual  of  Examinations 
Lyons  on  Fever  ..... 
Maisch's  Organic  Materia  Medica  . 
Marsh  on  the  Joints 
May  on  Diseases  of  Women  . 
Medical  News 

Medical  News  Visiting  List  . 
Medical  News  Physicians'  Ledger  . 
Meigs  on  Childbed  Fever 
Miller's  Practice  of  Surgery  . 
Miller's  Principles  of  Surgery 
Mitchell's  Nervous  Diseases  of  Women  . 
Morris  on  Diseases  of  the  Kidney  . 
Morris  on  Skin  Diseases 
Neill  and  Smith's  Compendium  of  Med.  Sci. 
Nettleship  on  Diseases  of  the  Eye  . 
Norris  and  Oliver  on  the  Eye 
Owen  on  Diseases  of  Children 
♦Parrish's  Practical  Pharmacy 
Parry  on  Extra-Uterine  Pregnancy 
Parvin's  Midwifery  .... 
Pavy  on  Digestion  and  its  Disorders 
Pepper's  System  of  Medicine 
Pepper's  Forensic  Medicine  . 
Pepper's  Surgical  Pathology 
Pick  on  Fractures  and  Dislocations 
Pirrie's  System  of  Surgery  .  . 
Playfair  on  Nerve  Prostration  and  Hysteria 
♦Playlair's  Midwifery  . 
Politzer  on  the  Ear  and  its  Diseases 
Power's  Human  Physiology  . 
Purdy  on  Bright's  Disease  and  Allied  Affections 
Ralfe's  Clinical  Chemistry 
Ramsbotham  on  Parturition 
Remsen's  Theoretical  Chemistry  . 
♦Reynolds'  System  of  Medicine 
Richardson's  Preventive  Medicine 
Roberts  on  Urinary  Diseases 
Roberts'  Compend  of  Anatomy 
Roberts'  Principles  and  Practice  of  Surgery 
Robertson's  Physiological  Physics 
Ross  on  Nervous  Diseases 
Savage  on  Insanity,  including  Hysteria  . 
Schafer's  Essentials  of  Histology, 
Schreiber  on  Massage  .  . 
Seller  on  the  Throat,  Nose  and  Naso-Pharynx 
Series  of  Clinical  Manuals 
Simon's  Manual  of  Chemistry 
Skey's  Operative  Surgery 
Slade  on  Diphtheria  .... 
Smith  (Edward)  on  Consumption  . 
♦Smith  (J.  Lewis)  on  Children 
Smith's  Operative  Surgery  . 
Stllle  on  Cholera  .... 
*Still6  &  Maisch's  National  Dispensatory 
♦Stillfi's  Therapeutics  and  Materia  Medica 
Stimson  on  Fractures  and  Dislocations, 
Stimson's  Operative  Surgery 
Stokes  on  Fever  ..... 
Students'  Series  of  Manuals  . 
Sturges'  Clinical  Medicine  . 
Tanner  on  Signs  and  Diseases  of  Pregnancy 
Tanner's  Manual  of  Clinical  Medicine  . 
Taylor  on  Poisons  .... 
♦Taylor's  Medical  Jurisprudence  . 
Taylor's  Prin.  and  Prac.  of  Med.  Jurisprudence 
♦Thomas  on  Diseases  of  Women  . 
Thompson  on  Stricture 
Thompson  on  Urinary  Organs 
Tidy's  Legal  Medicine .... 
Todd  on  Acute  Diseases 
Treves'  Manual  of  Surgery  . 
Treves'  Surgical  Applied  Anatomy 
Treves  on  Intestinal  Obstruction  . 
Tuke  on  the  Influence  of  Mind  on  the  Body 
Visiting  List,  The  Medical  News  . 
Walshe  on  the  Heart  .... 
Watson's  Practice  of  Physic  . 
♦Wells  on  the  Eye  .... 
West  on  Diseases  of  Childhood 
West  on  Diseases  of  Women 
West  on  Nervous  Disorders  in  Childhood 
Williams  on  Consumption  . 
Wilson's  Handbook  of  Cutaneous  Medicine 
Wilson's  Human  Anatomy  . 
Winckel  on  Pathol,  and  Treatment  of  Childbed 
Wohler's  Organic  Chemistry 
Wood  head's  Practical  Pathology  . 
Year-Books  of  Treatment  for  1885  and  1886 


26 
29 
4,13 
30 
18 
14 
23 
23 
31 
31 
25 


Books  marked  *  are  also  bound  in  half  Kussia. 


LEA  BROTHERS  &  CO.,  Philadelphia, 


Bellevue 


Hospital  Medical 

CITY  OF  NEW  YORK. 

Sessions  of  1887-88. 


College, 


The  Regular  Session  begins  on  Wednesday,  September  21,  1887,  and  ends  about 
the  middle  of  March,  1888.  During  this  Session,  in  addition  to  the  regular  didactic 
lectures,  two  or  three  hours  are  daily  allotted  to  clinical  instruction.  Attendance  upon 
at  least  two  regular  courses  of  lectures  is  required  for  graduation. 

The  Spring  Session  consists  of  recitations,  clinical  lectures  and  exercises,  and 
didactic  lectures  on  special  subjects.  This  Session  begins  about  the  middle  of  March 
and  continues  until  the  middle  of  June.  During  the  Session,  daily  recitations  in  all 
■  the  departments  are  held  by  a  corps  of  Examiners  appointed  by  the  Faculty. 

The  Carnegie  Laboratory  is  open  during  the  collegiate  year,  for  instruction  in 
microscopical  examinations  of  urine,  practical  demonstrations  in  medical  and  surgical 
pathology,  and  lessons  in  normal  histology  and  pathology,  including  bacteriology. 

For  the  annual  Circular  and  Catalogue,  giving  requirements  for  graduation  and 
other  information,  address  Prof.  Austin  Flint,  Secretary,  Bellevue  Hospital  Medical 
College,  foot  of  East  26th  Street,  New  York  City. 


Lea  Brothers  &  Co.'s  Publications. 


BRUNTON'S  THERAPEUTICS  AND  MATERIA  ME3DICA. 
A  Text-book  of  Pharmacology,  Therapeutics,  and  Materia  Medica. 

Including  the  Pharmacy,  the  Physiological  Action,  and  the  Therapeutical  Uses  of  Drugs. 
By  T.  Lauder  Bfiunton,  M.D..  F.R.S.,  F.R.C  P.,  Lecturer  on  Materia  Medica  and  Therapeu- 
tics at  St.  Bartholomew's  Hospital,  etc.  In  one  handsome  octavo  volume  of  1033  pages,  with 
188  illustrations.    Cloth,  $5.50;  leather,  $6.50. 

It  is  not  only  profoundly  scientific,  but  thoroughly  or  any  other  language.    Everything  is  practical,  the 

practical.    Indeed,  every  ohapter  teems  with  matter  dry,  hard  facts  of  physiology,  being  pressed  into 

of  the  greatest  practical  importance.    We  may  justly  service  and  applied  to  the  treatment  of  the  commonest 

sajr  that  the  student  will  find  in  it  a  thorough  and  complaints.    The  information  is  so  systematically  ar- 

trustworthy  text-book,  the  practitioner  a  guide  which  ranged  that  it  is  available  for  immediate  use.  The 

contains  all  the  real  therapeutic  information  gained  index  is  so  carefully  compiled  that  a  reference  to  any 

by  empirical  and  scientific  methods,  and  the  pharma-  special  point  is  at  once  obtainable.    Dr.  Brunton  is 

cologist  such  a  masterly  exposition  of  the  methods  of  never  satisfied  with  vague  generalities,  but  gives  clear 

investigation  that  he  will  consult  its  lucid  pages  on  and  precise  directions  for  prescribing  the  various  drugs 

all  occasions. — The  American  Journal  of  the  Medical  and  preparations.   We  congratulate  students  on  being 

Sciences,  April,  1886.  at  last  placed  in  possession  of  a  scientific  treatise  of 

It  is  a  scientific  treatise  worthy  to  be  ranked  with  the  enormous  practical  importance — Tlie  London  Lancet, 

highest  productions  in  physiology,  either  in  our  own  June  27,  1885. 


ASHHURST'S  SURGERY.— Fourth  Edition. 
The  Principles  and  Practice  of  Surg-ery.    By  John  Ashhurst,  Jr., 

M.D.,  Professor  of  Clinical  Surgery  in  the  University  of  Pennsylvania,  Surgeon  to  the  Episcopal 
Hospital,  Philadelphia.  New  (fourth)  edition,  enlarged  and  revised.  In  one  large  and  hand- 
some octavo  volume  of  1114  pages,  with  597  illustrations.  Cloth,  $6  00;  leather,  $7.00;  half 
Russia,  $7.50. 

Every  advance  in  surgery  worth  notice,  chronicled  j  in  the  English  language,  valuable  alike  to  the  student 
in  recent  literature,  has  been  suitably  recognized  and  and  the  practitioner,  to  the  one  as  a  text-book,  to  the 
noted  in  its  proper  place.  Suffice  it  to  say,  we  regard  other  as  a  manual  of  practical  surgery.  With  pleasure 
Ashhurst's  Surgery,  as  now  presented  in  the  fourth  |  we  give  this  volume  our  endorsement  in  full.-  Stir 
edition,  as  the  best  single  volume  on  surgery  published    Orleans  Medical  and  Surgical  Journal,  Jan.,  L888, 


4Sf  Full  descriptive  catalogue  will  be  found  preceding  this  page. 

LEA  BROTHERS  &  CO.,  706  and  708  Sansom  St.,  Philadelphia 


1888. 

THE  MONTHLY  PUBLICATION  OF 

The  American  Journal  of  the  Medical  Sciences. 

Octavo,  over  100  pages.   Issued  each  month,  $4  per  annum. 

The  publishers  have  great  pleasure  in  announcing  that  with  the  coming  New  Year 
The  American  Journal  will  appear  at  the  beginning  of  each  month,  and  that  the 
price  will  be  reduced  from  Five  to  Four  Dollars  per  annum.  At  first  sight  such 
sweeping  changes  seem  commercially  hazardous,  yet  estimates  based  on  the  largely  in- 
creased practical  value  of  a  monthly  as  compared  with  a  quarterly  show  that  the  risk 
is  justifiable.  Be  that  as  it  may,  the  new  departure  is  simply  in  keeping  with  that 
spirit  of  enterprise  which  has  made  The  Journal  during  two  generations  the  leading 
artery  of  medical  communication  in  this  country,  and  has  maintained  the  house  of  its 
publication  in  a  position  of  honor  and  usefulness  for  more  than  a  century. 

In  entering  on  the  development  of  its  new  possibilities,  The  Journal  will  undergo 
certain  changes.  Preserving  its  octavo  form  and  general  appearance,  it  will  of  course 
be  issued  in  smaller  individual  parts,  thereby  gaining  in  convenience  of  mental  and 
physical  grasp.  A  larger  proportion  of  space  will  be  assigned  to  Original  Articles, 
which,  on  an  average,  will  be  shorter,  so  that  every  reader  will  not  fail  to  find  in  each 
number  something  of  direct  interest  to  himself..  The  Department  of  Progress  will 
continue  to  furnish  its  most  valuable  summaries  of  advances  made  in  all  branches  of 
medical  science.  To  accommodate  the  increased  amount  of  space  thus  required  the 
Keviews  will  be  condensed,  yet  without  the  sacrifice  of  their  characteristic  thorough- 
ness and  impartiality.  It  needs  no  prophetic  vision  to  see  in  the  monthly  Journal 
at  once  the  most  valuable  and  least  costly  adjuvant  of  its  class  which  has  ever  been 
placed  at  the  command  of  the  professional  man  in  active  practice. 

Necessarily  different  in  their  spheres,  The  Journal  and  the  weekly  Medical  News 
are  mutually  supplementary,  and  every  reader  of  both  periodicals  may  feel  assured 
that  nothing  in  the  life  of  the  great  medical  world  will  escape  his  attention.  In  order 
to  lead  each  subscriber  to  prove  this  fact  for  himself,  the  Commutation  Rate  for  The 
Journal  and  The  News  has  been  placed  at  the  exceedingly  low  figure  of  $7.50,  in 
advance. 


THE  MEDICAL  NEWS. 

Five  Dollars  per  Annum. 

A.  National  Weekly  Medical  Periodical,  containing  28-32  Double- Columned  Quarto 
Pages  of  Heading  Matter  in  each  Issue. 

Uniting  in  itself  the  best  characteristics  of  the  magazine  and  the  newspaper,  The 
Medical  News  renders  a  service  of  exceptional  value  to  the  profession.  It  presents 
original  articles,  hospital  notes,  and  clinical  lectures  by  the  ablest  writers  and  teachers 
of  the  day,  discusses  living  topics  editorially  in  a  clear  and  scholarly  manner,  fur- 
nishes skilfully  condensed  abstracts  showing  the  Progress  of  Medicine  in  all  parts  of 
the  world,  and  employs  all  the  recent  and  approved  methods  of  medical  journalism — 
the  telegraph,  reporters,  and  a  corps  of  ecial  correspondents  covering  all  the  medical 
centres  of  the  globe.  In  short,  The  News  carries  to  its  readers  each  week  early  and 
concise  intelligence  bearing  on  all  departments  of  medical  science. 

COMMUTATION  RATE— REDUCED. 

The  American  Journal  of  the  Medical  Science  (monthly),  $4,  and  I  To  one  address,  $7.50 
The  Medical  News  (weekly),  $5.  )    per  annum  in  advance. 

The  Medical  News  Visiting  List,  for  1888. 

Now  in  press,  will  contains  48  pa^es  of  useful  data  and  176  pages  of  ruled  blanks  of 
various  kinds,  in  short,  every  possible  convenience  for  assisting  in  daily  practice  and 
recording  its  details  and  results.  Leather  bound,  tuck,  pocket,  pencil,  rubber,  and 
catheter  scale.  It  will  je  issued  in  three  styles,  Weekly,  for  80  patients,  Monthly,  and 
Perpetual.    Each  in  one  volume,  price  §1.25. 

SPECIAL  OFFERS. 

Advance-paying  subscribers  to  either  or  both  of  the  above  journals  may  obtain  The 
Medical  News  Visiting  List  or  The  Year  'Book  op  Treatment,  for  75  cents  each  (regular 
price  $1.25),  or  The  Journal,  The  News,  The  Visiting  List,  and  The  Year  Book  for  $S.50. 


LEA  BROTHERS  &  CO.,  Nos.  706  and  708  Sansoni  Street,  Philadelphia. 


i